|Year : 2018 | Volume
| Issue : 5 | Page : 44-48
Dissociative disorders: Reinvention or reconceptualization of the concept?
Nidhi Malhotra, Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India
|Date of Web Publication||20-Nov-2018|
Dr. Nitin Gupta
Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh - 160 030
Source of Support: None, Conflict of Interest: None
“Dissociative disorders” have existed since antiquity, but the concept has undergone major transformations over time. The presence of different theoretical explanations; lack of consensus regarding nosological status; inconclusive evidence with respect to relationship with trauma; and lack of clear evidence of the presence of neurophysiological disturbances are reflections of the fact that there is still lack of clarity with regard to classification of dissociative disorders. Notwithstanding these caveats, there have been significant advances in these areas in recent times, which have contributed to better understanding of dissociative disorders. The current write-up attempts to provide an insight into the evolution of the concept over time, related controversies, and the current nosological debate regarding dissociative disorders.
Keywords: Dissociative disorder, international classification of diseases 11, nosology
|How to cite this article:|
Malhotra N, Gupta N. Dissociative disorders: Reinvention or reconceptualization of the concept?. Indian J Soc Psychiatry 2018;34, Suppl S1:44-8
|How to cite this URL:|
Malhotra N, Gupta N. Dissociative disorders: Reinvention or reconceptualization of the concept?. Indian J Soc Psychiatry [serial online] 2018 [cited 2019 Apr 19];34, Suppl S1:44-8. Available from: http://www.indjsp.org/text.asp?2018/34/5/44/245834
| Introduction|| |
The nosology of dissociative disorders has been controversial since ages. The lack of clear neurobiological underpinnings, varying theoretical explanations, proximity to somatoform, and conversion disorders and different stances held by two major classificatory systems are challenges to understanding dissociative disorders. This chapter attempts to provide a chronology of evolution of the concept, attendant controversies, and nosological debates on these enigmatic disorders.
| Historical Background|| |
Although the term “dissociation” was first coined by Pierre Janet, dissociative phenomena have been recognized since antiquity. The concept of hysteria dates back to the time of Hippocrates, when multiple unexplained bodily symptoms were attributed to the “wandering uterus.” Over time, new explanations for the phenomena surfaced ranging from demonic possession to emotional trauma. Pioneers such as Janet, Freud, and Charcot emphasized its emotional basis. Janet postulated that dissociation represented abnormal splitting of mental processes leading to compartmentalization of the personality, with segments becoming inaccessible to one another. The core of his theory was that memories and emotions that are unavailable to the conscious awareness are held in a separate state of consciousness. These “dissociated” memories and emotions could express themselves somatically in disturbances of vision, hearing, speech, movement, and sensation and psychologically in alterations of consciousness, memory, and identity. Janet's theory was supplanted by Freud's concept of “hysterical conversion.” Freud suggested that ideas or memories that were too unpleasant for conscious awareness got repressed into the dynamic unconscious, and were “converted” into physical symptoms to solve unbearable psychological conflicts. Although both Janet and Freud insisted on the emotional nature of hysteria, Janet studied the dissociative aspects of hysteria, while Freud studied the conversion aspects. Till this time, dissociation and conversion were subsumed in a unified concept of hysteria, and emotional trauma was believed to have a central role in the causation of dissociation.
| Evolution of the Concept|| |
Current conceptualizations of dissociation emphasize two broad approaches. Dissociation is either seen as a complex reaction to external trauma in a previously normal person or it is seen as a vulnerability/attribute of the person that increases the likelihood of its occurrence. These attributes include personality constructs, hypnotisability, mental absorption, and tendencies to fantasize, etc. The role of trauma is important in both these approaches. Within these frameworks, two most commonly accepted models of dissociation are the discrete behavioral state model and taxon model. “Discrete behavioral state” model conceptualizes dissociation as representation of altered states of consciousness. In a normal individual, maturation of areas of brain serving integrative functions helps in modulation of integrated states. It is postulated that recurrent traumatic experiences can hamper this integration and lead onto abrupt and discontinuous transitions between these states. The taxon model assumes that pathological dissociation states represent a different class of psychological orientation. Development of dissociation questionnaires have contributed to the latter conceptualization by placing vulnerable persons into different categories based on phenomenology of dissociative experiences.
A third stream of evidence based on functional neuroimaging findings suggests that environmentally driven alterations of cognition, perception, behavior, and self-related processing contribute to dissociative disorders and that these are accompanied by metabolic and possibly structural brain changes.,,
| Culture Issues|| |
Cultural factors have been shown to influence the presentation of various psychiatric disorders. In the context of psychiatric disorders, culture is known to influence the meanings and expressions people give to various emotions; the perception of signs as normal or abnormal; the presentation of psychopathology; illness-related behavior; and help-seeking behavior., One of the most commonly studied areas in cross-cultural psychiatric research is that of “culture-bound syndromes.” Culture-bound or culture-specific syndromes cover an extensive range of disorders occurring in particular cultural communities or ethnic groups. The behavioral manifestations or subjective experiences particular to these disorders may or may not correspond to diagnostic categories in the classificatory systems. Many culture-bound syndromes such as amok, latah, and ataque de nervios present with symptoms similar to dissociative states in addition to the presence of other symptoms. Thus, culture can shape the presentation of dissociative disorders.
| Dissociative Disorders in Modern Classificatory Systems|| |
The International Classification of Diseases (ICD) and Diagnostic and Statistical Manual (DSM) have differed substantially regarding classification of dissociative disorders. The first edition of Diagnostic and Statistical Manual (DSM-I) placed “dissociative reaction” along with conversion, anxiety, and depressive “reactions” under the category of psychoneurotic disorders. However, in the second edition of the DSM, dissociative conditions were subsumed under the category of hysterical neurosis which was conceptualized to have conversion or dissociative subtypes. Thereafter, adopting an atheoretical approach to psychiatric diagnosis based on characteristic symptoms and longitudinal course, the construct of hysteria was dismembered and distributed among different diagnostic categories in the DSM-III. DSM-III defined the essential feature of dissociative disorders as “alteration in the normally integrative functions of consciousness, identity, or motor behavior.” The dissociative disorders included psychogenic amnesia, psychogenic fugue, multiple personality, depersonalization disorder, and atypical dissociative disorder. Conversion disorders were grouped with somatoform disorders. DSM-III-R described the essential feature of dissociative disorders as involving “alteration in the normally integrative functions of identity, memory, or consciousness,” replacing motor behavior with memory. In DSM-IV, perception was added to the previous list. Finally, the fifth edition of the DSM-5 describes dissociative disorders as broadly involving impairments in the integration of all of the following: “consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior.” In DSM-5, the diagnosis of depersonalization disorder was changed to “depersonalization/derealization disorder” and dissociative fugue was added as a specifier for the diagnosis of dissociative amnesia. Conversion disorder was retained in DSM-5 and it received a new subtitle: “functional neurological symptom disorder.”
The classification of dissociative disorders in the American diagnostic system for mental disorders fell out of line with the international diagnostic system in the late 20th century. The ICD-9 (1978) included dissociative (including “hysterical” amnesia and fugue and “dissociative” identity disorder), conversion (including “hysterical” blindness, deafness, paralysis, astasia-abasia, and “conversion hysteria or reaction”), and factitious disorders together in a single category. Separate categories were provided for somatoform disorders, depersonalization disorder (including derealization disorder), and hypochondriasis. Thus, in ICD-9, conversion was included with dissociation and separated from somatization. The ICD-10 (1992) also provided a category for both dissociative (including amnesia, fugue, stupor, and identity disturbance) and conversion (including “dissociative” motor disorder, aphonia, “dissociative” seizure/convulsion, “dissociative” sensory loss/deafness, and trance/possession) disorders together. Thus, ICD-10 retained the previous edition's classification of conversion and dissociation together, separate from somatization. ICD-10 excluded depersonalization disorder from the rubric of dissociative disorders on the ground that it does not involve a major loss of control over sensation, memory, or movement. Trance and possession disorder, which is in the DSM-5 category of dissociative disorder not otherwise specified, has a separate category in the ICD-10 nomenclature. The category of dissociative identity disorder is classified in “other dissociative disorder” in ICD-10.
| Dissociative disorders in International Classification of Diseases-11|| |
Many changes have been proposed in the category of dissociative disorders in the ICD-11 draft. It is now proposed that diagnosis of dissociative disorders requires “involuntary disruption or discontinuity in the normal integration of memories, thoughts, identity, affects, sensations, perceptions, behavior, or control over bodily movements.” Dissociative and conversion disorders are grouped together under the category of dissociative disorders. This is in line with ICD-10 and the original concept of hysteria. However, conversion disorders have been renamed as “dissociative neurological symptom disorders,” with the characteristic feature of “altered motor or sensory function that is not consistent with a recognized neurological disorder or other health condition.” Its subcategories include dissociative neurological symptom disorder, with seizures or convulsions, weakness or paralysis, alteration of sensation, symptoms of movement disorder, symptoms of gait disorder, cognitive symptoms, alteration of consciousness, visual symptoms, auditory symptoms, dizziness, and speech production.
The category of dissociative amnesia has been retained with the inclusion of dissociative fugue as a qualifier. Depersonalization-derealization disorder has been moved to the dissociative disorder category in ICD-11. Dissociative identity disorder has been shifted from unspecified dissociative disorders to a separate category, with the characteristic feature being the presence of two or more distinct, nonintegrated or incompletely integrated subsystems of the personality (dissociative identities), each of which exhibits a distinct pattern of experiencing, interpreting, and relating to itself, others, and the world. It is further specified for dissociative identity disorder that at least two dissociative identities should be capable of functioning in daily life, recurrently taking executive control of the individual's consciousness and functioning, and should include a substantial set of sensations, affects, thoughts, memories, and behaviors. A new category of “complex dissociative intrusion disorder” has been proposed, based on observations that many patients present with two or more distinct, nonintegrated or incompletely integrated dissociative identities, each of which exhibits a distinct pattern of experiencing, interpreting, and relating to itself, others, and the world. However, they cannot be diagnosed as dissociative identity disorder as only one identity is dominant. This new category will include such cases, wherein there is one dominant identity, but it is persistently and recurrently intruded on by components (i.e., dissociative intrusions) of one or more other dissociative identities, although these do not take full control over the person's consciousness and behavior. Trance and possession disorders will be retained; however, they will be separated into “trance” and “possession trance” disorder.
Currently, field trials are being conducted to test out these diagnostic guidelines on clinical samples and look for ease of use, consistency, and problem areas.
| Comparison of Dissociative Disorders in Diagnostic and Statistical Manual-5 and International Classification of Diseases-11|| |
It can be seen that the two classificatory systems have followed their predecessors [Table 1]. Conversion disorders have been grouped with dissociative disorders in ICD-11, albeit under the new term “dissociative neurological symptom disorder.” DSM-5 has continued to place dissociative disorders separately from conversion disorder (functional neurological symptom disorder) which continues to be grouped with “somatic symptom and related disorders.” Trance disorder is a separate category in ICD-11, whereas it is included in the “other specified” category in DSM-5.
|Table 1: Comparison of International Classification of Diseases-11 and Diagnostic and Statistical Manual-5 Classificatory Systems|
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A few changes in the ICD-11 classification have, however, decreased the discrepancy between the two classificatory systems. On the lines of DSM-5, depersonalization and derealization have been moved to dissociative disorders; dissociative identity disorder has been given a separate category; and dissociative fugue has been added as a qualifier of dissociative amnesia. However, a new category of “complex dissociative intrusion disorder” has been added in ICD-11 but it is missing from DSM-5.
The proposed changes in ICD-11 seem to be influenced by the research evidence, attempt at harmonization with DSM-5, and historical continuity of the concept of dissociation. ICD-11 retains the original grouping of conversion disorders with dissociative disorders. The separation of conversion from dissociation and grouping of conversion with somatoform disorders in DSM has been strongly criticized. Bowman insisted that dissociative processes of Janet's patients included somatic disturbances of vision, hearing, speech, movement, and sensation as well as psychological alterations of consciousness, memory, and identity and thereafter therefore should be grouped together in diagnostic systems. Holmes et al. proposed that dissociative disorders can be qualitatively grouped into two different phenomena, namely detachment and compartmentalization. In their view, the concept of detachment incorporates depersonalization, derealization, and similar phenomena, whereas that of compartmentalization includes dissociative amnesia, fugue, identity disorder, conversion motor, and sensory symptoms. In line with this conceptualization and in harmony with DSM-5, depersonalization-derealization disorder has been included in dissociative disorders category in ICD-11.
The proposed change in nomenclature of dissociative disorders with neurological presentations (conversion reaction) as dissociative neurological symptom disorder is based on the evidence that neurophysiological disturbances play a role in manifestation of dissociative symptoms.,, This new term is also likely to reduce the stigma related to the terms such as hysteria, besides leading to greater acceptability of the term by neurologists, whose caseload include a substantial number of cases with functional neurological symptoms.
The move of dropping the diagnosis of dissociative fugue and including it only as a specifier of dissociative amnesia seems justified, as amnesia for personal identity is the most common feature of fugue; wandering away from home is uncommon and the disorder itself is relatively rare.,
An important issue that has not been addressed adequately is the influence of culture on presentation of dissociative disorders. DSM-5 has attempted to incorporate the role of culture on mental health issues by including a section dealing with culture-related diagnostic issues across most mental disorders and including a new section on cultural formulation interview. DSM-5, however, continues to include culture-bound syndromes in its appendix. ICD-10 diagnostic criteria for research included a brief section titled “culture-specific disorders,” with the provision that the need for these categories has been expressed less often in recent years. ICD-11 seems to be silent on culture-bound syndromes, emphasizing form in the content dichotomy in relation to dissociative psychopathology. Culture-bound syndromes with dissociative features known by different names among different cultures overlap with one another and involve discrete episodes of behavioral dyscontrol, shouting, echolalia, confusion, crying, exaggerated startle, and in the case of amok, attempts to kill others with varying cultural explanations for these behaviors such as consumption of magical potions or spirit possessions. Physicians emphasizing ‘form’ recognize these behavioral syndromes as dissociative disorders. However, unless the unique cultural aspects of these disorders are recognized in the mainstream diagnostic classification, these will go unrecognized and unmanaged. ICD-11 provides an opportunity to relabel and include these conditions under the rubric of “unspecified dissociative disorders,” to improve their recognition, assessment, and treatment.
The use of the term “culture bound” has proved to be a road block. Perhaps they should be labeled as “folk diagnostic categories.”
| Conclusion|| |
Dissociative disorders can be called as the controversial child of Psychiatry since ancient times. Different theories have been put forward from time to time to understand these disorders. Initially, thought to be of purely emotional nature, these disorders are now being partly re-conceptualized as behavioral manifestations of underlying neurophysiological disturbances. The ICD-11 has taken into account the recent neurobiological conceptualizations to formulate the diagnostic categories of dissociative disorders but has retained the historical concept of dissociation. Despite persisting substantive differences in the classification of dissociative/conversion/depersonalization-derealization disorders across ICD-11 and DSM-5, there have been serious attempts at harmonization between the two classificatory systems. However, a major lacuna is the lack of inclusion of culture-bound syndromes with dissociation as the main presentation in the dissociative disorder category and this could lead to the failure of ensuring adequate recognition and treatment of these disorders.
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