Clinical Practice Guidelines for Assessment and Management of Dissociative Disorders Presenting as Psychiatric Emergencies

Abstract

INTRODUCTION Dissociative disorders are quite often present in emergency/casualty. Commonly seen presentations in India include dissociative convulsions, motor symptoms, possession states, at times dissociative amnesia, and dissociative fugue. Dissociative identity disorder is a very rare occurrence in the emergency setting. It is challenging to examine a patient with a dissociative disorder in the emergency setting, consider differential diagnoses, rule them out, and manage the acute symptoms. Lack of privacy and space, time available for assessment, and risk of misdiagnoses are some of the drawbacks of managing dissociative disorders in casualty. A decision about inpatient or outpatient management needs to be made. One must also ensure that the patient follows up for further evaluation and long-term management. There are no standardized practices while dealing with dissociative disorders in an emergency setting. In 2007, the Indian Psychiatric Society (IPS), published guidelines for the management of dissociative disorders. This was followed by an update on management in the child and adolescent age group in 2019 and one on psychological interventions in dissociative disorders in 2020. The current recommendations are primarily with respect to the management of dissociative disorders presenting as psychiatric emergencies. These will help clinicians in assessing, diagnosing, and treating dissociative disorders in an emergency setting. It is expected that these are tailored to suit the individual needs by the clinicians. EPIDEMIOLOGY In a retrospective study by Naskar et al.,[1] an analysis of patients being referred to the psychiatry services was done. Patients were referred for “medically unexplained somatic complaints” (47.70%) or with “no physical illness detected” in 38.59%. Out of 1,153 patients seen by psychiatric emergency services, 43.45% received a diagnosis belonging to the ICD 10 category of F40-49, neurotic, stress-related, and somatoform disorders. A study by Chaturvedi et al.,[2] reported the prevalence of dissociative disorders in the inpatient setting as 1.5 to 11.6 per 1000 and the outpatient setting as 1.5 to 15 per 1000. The commonest diagnosis among outpatients was dissociative motor disorder 43.3%, followed by dissociative convulsions 23.0% ad trance, and possession disorder 11.5%. Dissociative stupor was diagnosed in 6.6%, dissociative amnesia in 4.1%, mixed dissociative disorder in 4.1%, other dissociative disorders in 2.4%, dissociative fugue in 1.4%, and dissociative anesthesia in 0.8%. Similarly, the commonest diagnoses among inpatients were dissociative motor disorder (37.7%), dissociative convulsions (27.8%) the second most common followed by trance and possession disorders (5.3%), and dissociative stupor (5.3%). The unspecified dissociative disorders were seen in 6.3% of patients. Another retrospective analysis by Grover et al.,[3] reported the prevalence of dissociative disorders as 53.9% among anxiety disorders presenting in the emergency services. In a study conducted by Reddi[4] in the emergency psychiatric and acute care service of NIMHANS, the prevalence of dissociative disorders was 11.5 per 1000. The commonest presentation was dissociative motor disorder, dissociative convulsions. and mixed dissociative disorder. Dissociative disorders have seen an evolution in conceptualization and there are differences in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and The International Classification of Diseases, Tenth Revision (ICD-10) in the definition and diagnostic categories of dissociative disorders. Dissociative disorders according to ICD 10 are disorders characterized by having loss of the normal integration (partial or complete) between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.[5] DSM 5 defines dissociative disorders as “a disruption and/or discontinuity in the normal integration of different domains such as consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior”[6] Both ICD 10 and DSM 5 recognize the fact that dissociative disorders have physical as well as psychological symptoms. DSM 5 diagnoses conversion disorder as a part of somatic symptom disorders, whereas ICD 10 includes it in dissociative disorders. We have followed ICD 10 in the current guidelines. The following are the dissociative disorders as per ICD 10 [Table 1].[6]Table 1: List of dissociative disorders as per ICD-10Table 2 enlists the common types of dissociative disorders that are seen in the emergency department (ED).Table 2: Common presentations of dissociative disorders in an emergency departmentConcurrent psychiatric and physical illnesses are common in dissociative disorders. In the study by Reddi,[4] depressive disorder was seen in 11.2% of patients, adjustment disorder was seen in 3.1%, Cluster B was found in 9%, and Cluster C traits in 2.7% of patients. The risk of suicide was noted in 8% of patients. Epilepsy is known to occur with dissociative convulsions. A careful physical examination, a thorough mental state examination, and investigations to differentiate between medical illnesses and dissociative disorders are essential while managing dissociative disorders in an emergency setting. ASSESSMENT The outline for the assessment of dissociative disorders in the Emergency Department has been displayed in the following flowchart [Figure 1]:Figure 1: Outline for the assessment of dissociative disorders presenting as psychiatric emergenciesStudies have shown that among all psychiatric referrals in emergency settings, a call for the assessment of suspected dissociative disorder is the most common.[7] The tendency of dissociative disorders to emulate physical disorders makes assessment especially tricky. A wide range of medical conditions could mimic symptoms of dissociative disorders, medical conditions may produce and/or exacerbate psychiatric symptoms in patients already suffering from a mental illness, patients with pre-existing medical conditions can develop psychiatric symptoms and occasionally medical conditions and dissociative disorders can arise together. Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality.[8] In contrast, many other psychiatric disorders can either present like or be present along with dissociative disorders. The differential diagnosis that needs to be considered is enumerated in Table 3 below.[9]Table 3: Differential diagnosis of a presentation of an acute dissociative episodeThe medical knowledge and skills a psychiatrist possesses are extremely valuable in an emergency, this is especially true for the evaluation of dissociative disorders. The assessment of suspected dissociative disorders in the ED can be guided by the following questions [Table 4]:Table 4: Guiding questions for the assessment of dissociative disordersHistory taking The importance of detailed questioning about the current and past episode from the patient and an informant and a comprehensive medical, family, personal, and premorbid history cannot be over-emphasized. Yet, focusing on certain specific pointers can act as clues toward making an accurate diagnosis for the patient. These have been discussed below. Onset, duration, and progression The general age of onset of dissociative disorders is believed to be late adolescence to early adulthood, dissociative identity disorder (DID) is an exception where the symptoms begin in early childhood. An equal number of males and females experience dissociative identity disorder; however, more females experience dissociative amnesia and dissociative movement disorders.[6] Various studies report the onset and termination of dissociative states as being sudden, the duration of each episode generally lasts for a few weeks or months, and at times more chronic states, particularly paralyses and anesthesias, may occur if they are associated with insolvable problems or interpersonal difficulties.[5] Precipitating stressors Dissociative disorders are closely associated in time with traumatic events, insoluble, and intolerable problems, or disturbed relationships. As per ICD 10, dissociation disorders can only be diagnosed if there is evidence for a clear association between the occurrence of a stressful event and the onset of dissociation symptoms even if the association is denied by the individual.[5] Dissociative amnesia is known to occur after traumatic events such as war, abuse, rape, accidents, head injuries, natural disasters, and the death of loved ones.[10] History of childhood trauma Among all psychiatric conditions, dissociative disorders are associated with the highest frequencies of adverse childhood experiences and hence a history of early-age trauma could be an indicator toward making a diagnosis. According to a meta-analysis of 34 retrospective studies, childhood maltreatment in the form of emotional neglect, sexual abuse, and physical abuse are more common in patients suffering from dissociative disorders of movement and sensation than in the controls.[11] Studies have consistently shown an association of DID with childhood abusive experiences typically by an attachment figure.[12] Dissociative amnesia is caused by several factors, one of which is traumatic events. These include war, abuse, rape, accidents, head injuries, and natural disasters. Dissociative amnesia is also caused by life stressors, such as abandonment, financial worries, the death of a loved one, or marriage.[10] Characteristic clinical presentations of dissociative disorders in emergency settings Dissociative Amnesia Dissociative amnesia is seen very infrequently in our emergency settings. In the study conducted by Reddi,[4] out of 187 patients with dissociative disorder, patients seen in the emergency and acute services only one patient had dissociative amnesia. Dissociative amnesia is characterized by memory loss where a person is unable to recall important information in their personal life. This is usually associated with severe trauma, severe emotional stress, and internal conflict. Usually, there is a history preceding the traumatic event. This memory loss cannot be explained by ordinary forgetfulness. It is not due to substance use or a medical condition [Table 5].[5]Table 5: Types of dissociative amnesia according to DSM 5[ 6 ]Patients present in the casualty with various features including physical symptoms, regression to younger age, depersonalization, derealization, perplexed effect, attention-seeking behavior, and trance states. Patients may have depression and a risk of suicide. There is often a history of trauma in childhood or in the past. Dissociative amnesia is often seen in combat-related trauma. These patients are usually young adults, and it is rarely seen in elderly individuals. A family history of somatoform disorders and dissociative disorders is seen in some patients.[5,13] Dissociative fugue It has all the features of dissociative amnesia, along a journey away from home or place of work. This journey characteristically appears purposeful, and the person’s self-care is maintained throughout. In some cases, during the period of travel, a new identity may be assumed with a surprising degree of completeness, and the individual’s behavior during this time may appear completely normal to independent observers. Organized travel may be to places previously known and of emotional significance.[5] Dissociative motor disorders The dissociative motor disorder includes loss of ability to move one or more than one limb, incoordination and/or trembling or shaking of one or more extremities or the whole body. Paralysis may be partial (presenting with weak or slow movements) or complete. Some dissociative motor disorders may be hard to differentiate from various forms of ataxia, apraxia, akinesia, aphonia, dysarthria, dyskinesia, or paralysis.[5] Dissociative anesthesia and sensory loss Cases of dissociative anesthesia and sensory loss generally present to the ED with complaints of sudden hemisensory loss or as a sensory loss not conforming to known neuroanatomical distributions, for example, anteriorly at the level of the trunk, without similar posterior involvement. Sensory complaints can be isolated or accompanied by motor weakness and are frequently associated with complaints of paraesthesia. Cases, commonly in children and adolescent age groups, can also present to the ED with dissociative visual loss (usually in the form of loss of visual acuity, blurring, or visual field restriction such as tunnel vision), and hearing loss.[14] Dissociative convulsions Dissociative convulsions are characterized by episodes similar to seizure episodes but do not have any seizure activity on video electroencephalogram (EEG). These episodes are characterized by various symptoms including motor, sensory, autonomic, and/or cognitive signs.[15] Dissociative convulsions are one of the commonest presentations in emergency settings in India.[4] Dissociative convulsions are not under the patient’s voluntary control and represent their involuntary response to emotional stress. Noteworthy points in clinical history include specific emotional triggers such as emotional arousal, pain, patterns such as head-shaking or irregular, asynchronous limb movements, noises, and light.[16] Trance and possessions Most cases of trance and possession disorder (commonly referred to as dissociative trance disorder or DTD) present with attacks of possession by culturally known local entities such as deities, the devil, malevolent spirits, deceased relatives or ancestors, and animals. Very frequently, the episodes are associated with visual/auditory hallucinations, fearfulness, and paranoia, making them difficult to differentiate from acute psychotic disorders. The transient alteration in consciousness as a part of DTD can also be associated with self-mutilating behaviors including suicide attempts. Although possessed entities frequently threaten the accompanying family members with violence, physical acts of aggression toward others have been documented less commonly, including ritualistic homicide in rare cases.[17] Table 6 enlists the differentiating clinical features of the types of dissociative disorders.[5]Table 6: Differentiating clinical features between various types of dissociative disordersClinical features differentiating other psychiatric disorders Not so infrequently, other psychiatric disorders can themselves present with dissociative symptoms such as dissociative convulsions, depersonalization/derealization episodes. Dissociative symptoms can be observed in PTSD, psychotic disorders, mood disorders, and neurocognitive disorders. Some points that can help differentiate dissociative disorder from other psychiatric disorders are mentioned in Table 7.[15]Table 7: Differentiating dissociative disorder from other psychiatric disordersClinical features differentiating from intentional production of symptoms Considering the absence of organic etiopathogenesis and its associated investigative markers is a feature of dissociation, factitious, and malingering, differentiating between the three can be challenging and relies on history taking and clinical features. According to the model of compensation neurosis, conversion disorders, factious disorders, and malingering lie on a spectrum where the latter two are said to be intentionally produced, whereas the former is not. In factitious disorder, deceptive behavior has an internal motivation and is evident even in the absence of external rewards, whereas malingering is motivated by external incentives, such as an attempt to avoid working, obtain financial benefits, evade criminal charges, or procure drugs. Detailed past history often identifies the signs of simulation in childhood and adolescence. Careful examination of previous medical records shows an unusually large number of childhood illnesses along with signs of psychiatric disorders such as substance abuse, mood, and personality disorder. Another sign is the patient resisting access to information from other sources.[18] Clinical features to differentiate from medical disorders Ruling out medical disorders based on history is challenging; however, certain questions could indicate an organic pathology. Epilepsy is an important differential of dissociative disorders, clinical features differentiating dissociative convulsions and epilepsy is as mentioned below in Table 8.[19]Table 8: Differentiating between epileptic seizures and dissociative convulsionsAmnesia can also follow an episode of seizure. Complex partial seizures may occur along with automatisms. Transient global amnesia is seen in older individuals, cerebrovascular risk factors are present along with the sudden onset of anterograde amnesia, loss of new learning capacity, autobiographical memory intact, insight into memory loss present and there is complete recovery.[13] Clinical interview Interview of the patient can be done in an unstructured manner in the form of asking questions to the symptoms of dissociative disorders, some of the questions are in Table below. It can also be done in a manner in the form of [Table It is important to that along with these the importance of a comprehensive mental examination not be interview questions to dissociative Various assessment available for dissociative 15 examination A thorough examination is as important as a clinical history while a suspected of dissociative disorder in the The examination on out the medical as well as information in of a dissociative The is the to a diagnosis of dissociative disorders, especially of dissociative motor and/or sensory symptoms. can often be and to avoid the of signs may be in signs or by clinicians have more A and by et many signs for symptoms, they found that have been these to have but a that that even they are not present in patients with symptoms they help into dissociative disorders. These along with their are mentioned in Table Clinical signs during examination to dissociative a large number of medical disorders can present with dissociative symptoms, the investigations that can be done on an emergency are they are to in Table investigations in emergency settings while dissociative the of in disorders is in the patient’s focusing on the stressors than the dissociative episodes. an acute dissociative especially in with a illness, can be an extremely experience for the patient as well as their family from certain cases can also present a risk of to or in emergency settings, the most important for management are and symptom Table the to be for the of management of psychiatric in dissociative for the management of dissociative disorders presenting in the ED has been in 2: Outline of management of acute dissociative episode presenting in emergency The a dissociative disorder to the ED is to the of the patient and/or followed by symptom the points to be for the points while in an acute presentation of dissociative a The of a and with the patient and family members is for This makes it for the family members to the of particularly in cases where their behaviors and with the patient have a in the disorder. Similarly, a of and their of the symptoms is also In patients present with acute conversion symptoms such as or a dissociative the anxiety such as can help in the of the and help in early and along with to the patient a in a of the symptoms. Patients with dissociative disorders and a history of trauma often experience acute dissociative episodes characterized by a of emotional depersonalization, and of the traumatic past to or a patient may present to the ED in such a even if the present no any of are to the patient to and the present the of the dissociative depersonalization, it also in such including the in dissociative identity disorder The to the patient’s sensory awareness of the any of the or cognitive awareness of themselves and the of the present The are mentioned in Table that can be in emergency times dissociative disorders are in an acute or patients with personality disorder present they can present to the ED in a state of acute In such cases, of to the more of physical or it is to the acute by and to the This the personality the internal and the of to ensure Similarly, in the of the possession a of and frequently may be This the to its needs and it to the body. a of the of the symptoms is management to clinical presentations frequently with medical conditions and a tendency of to to more of very few studies have been to the management of dissociative disorders in an acute setting. from no have been or have been found to be for the management of dissociative disorders, there is a of psychiatric conditions such as depression or anxiety disorder. the management of dissociative disorders in emergency settings, and have been the most based on available from and of acute anxiety associated with a such as and can be per In cases where immediate is as in the of acute 2 can be or with in if In cases of severe psychotic particularly the between a psychotic disorder and dissociative disorder may be up to a of 5 can be along with can be the may be after to 2 of 5 with 2 may have an effect, but with a of the diagnosis of dissociative is are not after an acute seizure it must be noted that on as for managing acute episode can a in the patient. Similarly, in cases of patients with diagnoses of dissociative disorders to emergency services in an acute the family members be explained that are for dissociative symptoms. the may that the is unable to the presenting unnecessary on may to the members their on the of due to the that the will the symptoms. in some cases, of a with may also be to ensure of the patient and for further particularly in with psychological and in on of family members forms a part of the management even in acute settings. about the of the disorder and its symptoms and the of and for points have been mentioned in Table points to be to during dissociative of further management the acute symptoms have in the a for further management can be detailed further and managing interpersonal the of setting between and management has to be is in certain as mentioned in Table the patient can be to follow up on an for further for in dissociative disorder presenting as a psychiatric This the of in which dissociative disorders can present in an emergency setting and toward their diagnosis and acute management. There may be a significant between the presentation of dissociative disorders and medical illnesses in emergency settings. A detailed history the of the with stressful events, psychiatric and a thorough clinical examination is important to differentiate the In many cases, certain investigations may be a clear diagnosis. to the of psychiatric illnesses and the associated stressors, a management that includes as well as may be and of There are no of

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