Dissociative disorders are a set of disorders defined by a disturbance affecting functions that are normally integrated with a prevalence of 2.4 percent in industrialised countries. These disorders are often poorly diagnosed or misdiagnosed because of sharing common clinical features with psychotic disorders, but requiring a very different trajectory of care. Repeated clinical situations in a crisis centre in Geneva provided us with a critical overview of current evidence of knowledge in clinical and etiopathological field about dissociative disorders. Because of their multiple expressions and the overlap with psychotic disorders, we focused on the clinical aspects using three different situations to better understand their specificity and to extend our thinking to the relevance of terms “neurosis” and “psychosis.” Finally, we hope that this work might help physicians and psychiatrists to become more aware of this complex set of disorders while making a diagnosis.
Dissociative disorders are a complex syndrome because of multiple expressions and the wide variety, defined by disturbances of every area of psychological functioning, affecting functions that are normally integrated such as memory, consciousness, identity, emotion, perception, body representation, motor control, and behaviour [
Major changes in dissociative disorders in the recent fifth edition of DSM-5 include the following: (1) derealization is included in the name and symptom structure of what previously was called depersonalization disorder (depersonalization-derealization disorder); (2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis; and (3) the criteria for dissociative identity disorder were changed to indicate that symptoms of disruption of identity may be reported as well as observed and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experiences of pathological possession in some cultures are included in the description of identity disruption.
According to ICD-10, there are more subtypes of diagnostic categories and depersonalization/derealization disorder is classified in neurotic disorders (see Table
Classification of dissociative disorders in ICD-10 and DSM-5.
ICD-10 | DSM-5 | ||
---|---|---|---|
F44.0 | Dissociative amnesia | 300.12 | Dissociative amnesia without fugue |
F44.1 | Dissociative fugue | 300.13 | Dissociative amnesia with dissociative fugue |
F44.2 | Dissociative stupor | ||
F44.3 | States of obsession and dissociative trance | ||
F44.4 | Dissociative motor disorders | ||
F44.5 | Attacks of cramps dissociative | ||
F44.6 | Sensitivity disorders and dissociative sensory | ||
F44.7 | Mixed dissociative disorders | ||
F44.8 | Other dissociative disorders | ||
F44.80 | Ganser’s syndrome | ||
F44.81 | Multiple personality | 300.14 | Dissociative identity disorder |
F44.89 | Other specified dissociative disorders | 300.15 | Other specified dissociative disorders |
F44.9 | Unspecified dissociative disorders | 300.15 | Unspecified dissociative disorders |
F48.1 | Depersonalization/derealization disorder (up to neurotic disorders) | 300.6 | Depersonalization disorder (up to dissociation disorders) |
These classifications admit that dissociative disorders are psychogenic, that is, of purely mental origin [
The prevalence of dissociative disorders is close to 2.4 percent in industrialised countries [
Diagnostic of dissociative disorders can overlap with psychotic disorders, reflecting the close relationship between these diagnostic classes [
The history of the concept of dissociation goes back to the works of Charcot and Bernheim on hysteria and hypnosis and then those of Janet and Freud. With Bleuler, the concept of “dissociation” extends and is soon permanently reduced to some symptoms of schizophrenia, known from clinicians as “Spaltung,” a psychic disintegration expressed in discordant manifestations of thoughts, affects, and behaviour. This division contributes, even at the present time, to supply issues on the border, sometimes blurred, between hysterical symptoms, posttraumatic stress, and schizophrenia.
“The dissociation would focus on the body representation, in the direction of a separation of body and psyche
Moreover the dissociative disorders are frequently found in the aftermath of trauma, correlated or not with the emotional life during childhood [
We have evaluated and managed several clinical cases of dissociative disorders in the crisis centre of area-catchment of Jonction in Geneva, each one with distinct causes. To refine the diagnosis and optimise the care management of these clinical cases, we have performed a critical overview of current computerized evidence of knowledge (Medline).
Mr. A is a 32-year-old patient of Swiss origin. He works as an insurer. He has a partner whom he has been with for over 2 years and with whom he had a child. He talks about sexual abuse from one member of his own family members in the past but has only vague memories of this event. A diagnosis of paranoid schizophrenia was established 6 years ago, and the patient has been in remission for 5 years without antipsychotic treatment. The patient has contacted us to request a diagnostic evaluation in the context of a development.
With regard to mental status, the patient is calm and collaborating; his thoughts have an organised structure; he is well-oriented, and his hygiene and clothing are appropriate. His thymia is neutral and there are no elements of depressive symptomatology. His speech is coherent, fluid, and informative without delusional elements. His only “psychosis-like” symptomatology is the “voice hearings” in the form of voices that speak to him from within. He determines that these voices are coming from his own imagination.
Indeed, he describes constant oscillations between the presence of two distinct personalities, which he manages to differentiate. The first personality is described as that of a junkie (if he does not control himself, he lives as a person who needs to consume drugs and he goes into hiding in uninhabited buildings), and the other personality is described as that of a conformist modern man (i.e., clean looking, “well thinking,” and conforming to society’s standards; an attitude he adopts elsewhere, at work, for example).
His mental status reveals the characteristics of a dissociative identity disorder. There are two distinct identities or “States of personality” in this patient; they take turns at controlling the behaviour of the patient. The disturbance is not due to the direct effects of a substance or a general medical condition. Moreover, he does not have psychotic symptomatology. He describes that the voices are coming from the inside of himself (each of the personalities interacts with him, alternately). He has no other comorbid disorder. He has one meeting a month for supportive psychotherapy. He is not treated with psychotropic medication.
Mrs. B is a 44-year-old patient who has been married for 24 years; she lives with her husband and their 2 teenage children. She has no known psychiatric history. The authority of parenting has been a traumatic experience, and she has a self-assertion deficit.
She consulted the psychiatric emergency department in 2012, accompanied by her family. She presented with a behaviour disorder of gradual emergence, in the form of psychomotor agitation and “sexual” exhibition. She also had voice hearings (she hears from “an angel” coming from inside that predicts upcoming events and guides her). The self-criticism is retained. The emergency psychiatrist felt that this was a psychotic disorder not otherwise specified; he administered an anxiolytic medication (lorazepam) to quickly tranquilise the patient and transferred her to the crisis centre. Upon admission, the patient had significantly intense anxiety, had a situational mild to moderate spatiotemporal disturbance, and was confused. Her mood was sad, with minor anhedonia and minor abulia. She had a sleep disorder for three days, with insomnia at the beginning and at the end of the night. Her speech was coherent, informative, fluid, and critical in the aftermath (she says that she hears the voice of an angel, which she identifies as a production of her own imagination). Considering the persistent “psychosis-like” and mass anxiety symptomatology, antipsychotic treatment with olanzapine was administered, and it was recommended that the patient stays a few nights in the centre for further care. The presence of a comorbid depressive disorder (MADRS scale score of 19) led us to prescribe an antidepressant treatment, trazodone; the dose was increased gradually to 200 mg per day. The “psychosis-like” symptomatology started improving quickly, within 48 h, and the antipsychotic treatment was stopped. The patient was able to return home after 3 days and was followed up every week with two interview sessions. During her followup, thymic improvement was noted, with a return of the vital impetus and a decrease in the anxiety but with the emergence of a diffuse painful syndrome. Her treatment is one-session psychotherapy per week and trazodone 200 mg per day.
Mrs. C is a 33-year-old patient who is a law graduate. She is married and does not have any children. She presented with a major depressive disorder of moderate intensity, generalised anxiety, and a history of alcohol dependence (having been sober for a few months). She was hospitalised for the first time in the psychiatric department for 10 days, a few weeks before we met her, due to a diagnosis of “acute and transitory psychotic disorder” (with voice hearings and a behavioural disorder that has medicolegal impacts), which has been linked to disulfiram treatment; the evolution of this disorder has been favourable with olanzapine 10 mg/day and then quetiapine 200 mg/day, in addition to the usual treatment of venlafaxine 75 mg/day. Subsequently, this patient was treated in our ambulatory unit, where risperidone 1 mg/day was prescribed, and then she was hospitalised again in the psychiatric clinic for one month. Venlafaxine was replaced by escitalopram. The dose of escitalopram was decreased to 30 mg/day as a result of an increase in her liver enzymes. We also substituted pregabalin for olanzapine 5 mg/day (which was reintroduced during the 2nd hospitalisation), because of increased feelings of depersonalization-derealization, which means a feeling of “getting out of her body,” which she described “as if” she was an automaton and having recurring feelings of being detached from herself. The patient had an improvement in her depressive symptomatology (MADRS score of 32 at admission and 12 over the course of treatment) under escitalopram 30 mg/day and pregabalin 200 mg/day. However, there was a persistence of moderate anxiety. She did not have any psychotic symptomatology. She benefitted from analytical psychotherapy with one meeting per week.
The growing clinical interest in the different forms of dissociative disorders has led us to carry out a brief review of the literature, supported by three clinical cases to highlight this complex disorder. Dissociative disorders are difficult to distinguish from psychotic disorders not only because of the close proximity of phenomenological elements but also because of a linked aetiology due to trauma, triggering sometimes both disorders. This is further complicated by other comorbid disorders, which are often present. Authors have reported association with an anxiety disorder [
We noted that Mrs. B presented conversion symptoms (formerly classified as hysterical), which were theatrical (there was powerful staging in front of her family) with sexual thematic (showing off nude in front of her close relations and people in her immediate environment), and she had voice hearings (pseudohallucinations) [
However, there are only limited data on the effectiveness of drug treatments for dissociative disorders. The psychopharmacological approach is the foremost treatment based on the presence of other comorbidities. Selective serotonin reuptake inhibitors (SSRIs) treatment allows for the reduction of comorbidities, such as anxiety and depressive symptoms, although SSRIs have little effect on the dissociative disorder itself. We treated the patient with an antidepressant to reduce both the depressive and anxiety symptomatology and the pains associated with the symptoms. Psychotherapeutic support was given in the form of psychodynamic and systemic inspiration.
The symptoms Mr. A presented were likely to generate a diagnostic error, being the differential diagnosis between a psychotic disorder and a dissociative disorder close in this case. We established a diagnosis of dissociative identity disorder for this patient, who was previously diagnosed with schizophrenia. In fact, 25 to 50% of people diagnosed with a dissociative disorder are already affected by schizophrenia [
Concerning the treatment of Mrs. C, she had received a diagnosis of acute and transitional psychotic disorder treated with an antipsychotic treatment. However, this was called into question due to the traced history of the postcrisis symptomatology. She described feeling detached from herself, of “getting out of her own body,” she described voices heard internally (pseudohallucinations), and she retained morbid conscience, in the context of mass anxiety. These elements enabled us to diagnose a depersonalization-derealization disorder, which is a dissociative disorder according to DSM-5 but which is considered as a neurotic trouble in ICD-10. Concerning patients with depersonalization-derealization, they frequently use the expression “it is as if” [
This patient received treatment with pregabalin for generalised anxiety and a selective serotonin reuptake inhibitor (escitalopram) for major depressive disorder but received no other treatment for the depersonalization-derealization disorder. Antipsychotic drugs are sometimes used to treat the depersonalization-derealization disorder; however, their effectiveness has not been demonstrated in any controlled study, and the emergence of depersonalization-derealization has been reported under antipsychotics [
The therapeutic approaches used for dissociative disorders correspond to the three basic models: cognitive-behavioural, psychodynamic, and systemic therapy. Psychotherapeutic treatments, which appear to be the most effective so far, are the EMDR [
We assume that it is important to distinguish voice hearings experiences coming from inside (pseudohallucinations) in the dissociative disorder from those coming from outside (auditory hallucinations) in psychosis.
We have identified that dissociative disorders are a kind of trouble close to psychotic disorders because of voice hearings experiences inter alia. The “psychosis-like” symptoms (behavioural disorders, agitation, (auditory) pseudohallucinations, and pseudodelusions) are a part of dissociative disorder, giving this diagnosis hard to make. Other “psychosis-like” symptoms are the confusion and the impression to be in a “dream,” to be detached from feelings and to live something “as if.” We are aware that this is specific of depersonalization-derealization disorder, a dissociative disorder according to the DSM-5.
Finally, the specific symptoms we described in this paper allowed us suggesting that dissociative disorders are a set of troubles at the border between neurosis and psychosis. The main question of this work was to know if the dissociative disorders belong to the group of neurosis or to the one of psychosis. Are they on the border between these two entities as the clinical symptomatology and the history show us? The fact that this disorder frequently appears among patients, especially with a borderline personality disorder, points the argumentation of this discussed border leading to prospects for theoretical model of dissociative personality structure [
Adequate and well-adapted therapeutic treatment for these clinical cases of dissociative disorders has resulted in a favourable outcome in our crisis centre. We have identified that dissociative disorders are a kind of trouble close to psychotic disorders on one hand, because of voice hearing experiences inter alia, and close to neurotic disorders on the other hand, because of intact reality testing inter alia. We therefore suggest keeping focus on descriptive clinical symptomatology in this case. Further clinical studies, theoretical approaches, and reflections about this complex disorder are suitable.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The authors would like to thank all the multidisciplinary team of the mental health catchment of Jonction who gave them their help to do this work and who gives everyday optimal care to patients.