Download Microsoft PowerPoint - DSM-5Dissociative Disorders \252\272\266E

Dissociative Disorders
DSM-5 Dissociative Disorders
的診斷改變
周勵志
新光醫院精神科
台灣向日葵全人關懷協會
DSM-5執行小組教育訓練負責人
• This category contains diagnoses that were
listed in DSM-IV under the chapter of
Dissociative Disorders.
• The Anxiety, Obsessive-Compulsive
Spectrum, Posttraumatic, and Dissociative
Disorders Work Group has been responsible
for addressing these disorders.
http://www.dsm5.org/proposedrevision/Pages/
DissociativeDisorders.aspx
Definition of Dissociation
• A disruption of and/or discontinuity
in the normal, subjective integration of one or
more aspects of psychological functioning,
including—but not limited to—memory,
identity, consciousness, perception, and
motor control.
• In essence, aspects of psychobiological
functioning that should be associated,
coordinated, and/or linked are not.
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
Definition of Dissociation
Dissociative Symptoms
Dissociative Symptoms
• Acute pathological dissociative presentations,
the dissociation is primarily related to
traumatic and/or overwhelming experiences.
• In life-long dissociative presentations such as
Dissociative Identity Disorder (DID)
dissociative symptoms may routinely also
occur in circumstances that are unrelated to
trauma or overwhelming circumstances.
(a) Unbidden and unpleasant intrusions into
awareness and behavior, with
accompanying losses of continuity in
subjective experience: (i.e. ‘‘positive’’
dissociative symptoms);
(b) an inability to access information or
to control mental functions that normally are
readily amenable to access or control: (i.e. ’’
negative’’ dissociative symptoms).
• In the literature, dissociation is described
both as a dimensional adaptation as well as a
categorical form of psychopathology.
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
1
Dissociative Smptoms & the
Subjective Experience of Dissociation
DSM-IV vs. ICD-10
• Age of onset
• Life-long adaptation
not everyone has amnesia
‘‘amnesia for amnesia’’
• Consequence of the dissociation
• Reduce subjective distress
• Essential feature
DSM-IV: a disruption in the ‘‘usually
integrated functions of consciousness,
memory, identity, or perception.’’
ICD-10: a partial or complete loss of the
normal integration between memories of the
past, awareness of identity and immediate
sensations, and control of bodily movements.’’
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
DSM-IV vs. ICD-10
• Duration
DSM-IV: several DDs as long-term, chronic
disorders, including DID and some forms of
DPD, DA, and DDNOS.
ICD-10: primarily acute disorders that usually
remit within a few weeks or months, and that
have an onset in the immediate context of
events that are highly stressful, traumatic,
and/or that involve intolerable, insoluble
problems.
Spiegel D, et al
Depress Anxiety 2011; 28:825-52
Dissociative Disorders in DSM-5
H 00 Depersonalization/Derealization Disorder
H 01 Dissociative Amnesia
H 02 Dissociative Identity Disorder
H 03 Substance-Induced Dissociative Disorder
H 04 Other Specified Dissociative Disorders
H 05 Unspecified Dissociative Disorder
http://www.dsm5.org/proposedrevision/Pages
/DissociativeDisorders.aspx
Functional Neurological Disorder
(Conversion Disorder)
• Criteria A, B, C, and D must all be fulfilled to
make the diagnosis:
A. One or more neurologic symptoms such as
altered voluntary motor, sensory function,
cognition, or seizure-like episodes.
B. The symptom, after appropriate medical
assessment, is found not to be due to a
general medical condition, the direct effects
of a substance, or a culturally sanctioned
behavior.
2
Functional Neurological Disorder
(Conversion Disorder)
• Criteria A, B, C, and D must all be fulfilled to
make the diagnosis:
C. The physical signs or diagnostic findings are
internally inconsistent or incongruent with
recognized neurological disorder.
D. The symptom causes clinically significant
distress or impairment in social, occupational,
or other important areas of functioning or
warrants medical evaluation.
Depersonalization/Derealization Disorder
Rationale
• Depersonalization disorder should retain its
classification as a dissociative disorder in its current
form. However, it is problematic that chronic
derealization is not included in the diagnosis.
• DSM-IV-TR derealization classified with DDNOS,
which is not in line with the ICD which has
depersonalization-derealization as a single disorder.
• Recent empirical evidence that individuals with
prominent derealization alone do not significantly
differ from those with depersonalization
accompanied with derealization in any respect,
including demographics, precipitants, illness
characteristics, and comorbidity (Simeon 2009)
Depersonalization/Derealization Disorder
• Either (1), (2), or both:
A1. Depersonalization: Persistent or recurrent
experiences of feeling detached from, and as if one
is an outside observer of, one’s mental processes or
body (e.g., feeling as though one is in a dream;
sense of unreality of self or body; or time moving
slowly)
A2. Derealization: Persistent or recurrent
experiences of unreality of surroundings (e.g.,
world around the person is experienced as unreal,
dreamlike, distant, or distorted)
B. During the depersonalization or derealization
experience, reality testing remains intact
Dissociative Amnesia
A. Inability to recall important personal
information, usually of a traumatic or stressful
nature, that is inconsistent with ordinary
forgetting. Note: There are two primary forms of
Dissociative Amnesia: (1) localized amnesia for a
specific event or events, and (2) Dissociative
Fugue: generalized amnesia for identity and life
history. Fugue may be accompanied by either
purposeful travel or bewildered wandering.
B. The symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
Depersonalization/Derealization Disorder
C. The depersonalization or derealization symptoms cause
clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The depersonalization or derealization symptoms are not due
to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g.,
complex partial seizures).
E. The depersonalization or derealization symptoms are not
restricted to the symptoms of another mental disorder
(e.g.,schizophrenia, panic disorder, acute stress disorder,
posttraumatic stress disorder, major depressive disorder, or
another dissociative disorder).
Specify if:
a) Depersonalization only
b) Derealization only
Dissociative Amnesia
C. The memory loss is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication)
or a neurological or other general medical condition (e.g.,
Amnestic Disorder Due to Head Trauma).
D. The memory loss is not restricted to the symptoms of
another mental disorder (e.g., inability to remember an
important aspect of the traumatic event in Posttraumatic
Stress Disorder or Acute Stress Disorder, or amnesia
occurring as a symptom of Dissociative Identity Disorder
or Somatization Disorder).
Specify if:
Dissociative Fugue subtype:
1. Amnesia includes inability to recall one’s past, confusion
about personal identity, or assumption of a new identity
(partial or complete)
2. Sudden, unexpected travel away from home or work.
3
Dissociative Amnesia
Rationale
• A. Minor wording changes for clarity.
• B and C switched.
• Changes to new C allow comorbid diagnoses
to be made when warranted.
• Dissociative Fugue: dissociative amnesia,
usually for identity, is the primary feature,
and travel is an inconsistent one. Also, the
disorder is extremely rare, so inclusion as a
subtype of Dissociative Amnesia seems
reasonable.
Dissociative Identity Disorder
D. The disturbance is not a normal part of a broadly
accepted cultural or religious practice and is not due
to the direct physiological effects of a substance (e.g.,
blackouts or chaotic behavior during Alcohol
intoxication) or a general medical condition (e.g.,
complex partial seizures). NOTE: In children, the
symptoms are not attributable to imaginary
playmates or other fantasy play.
Specify if:**
a) With non-epileptic seizures or other conversion
symptoms
b) With somatic symptoms that vary across identities
(excluding those in specifier a)
Dissociative Identity Disorder
A. Disruption of identity characterized by two or more
distinct personality states or an experience of
possession, as evidenced by discontinuities in sense
of self, cognition, behavior, affect, perceptions,
and/or memories. This disruption may be observed
by others or reported by the patient.
B. Inability to recall important personal information,
for everyday events or traumatic events, that is
inconsistent with ordinary forgetfulness.
C. Causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning. *
Pathological Possession Trance
• Possession trance involves replacement of the
customary sense of personal identity by a new
identity, attributed to the influence of a spirit,
power, deity, or other person, and associated
with stereotyped “involuntary” movements or
amnesia and is perhaps the most common
Dissociative Disorder in Asia. Examples include
amok (Indonesia), bebainan (Indonesia), latah
(Malaysia), pibloktoq (Arctic), ataque de nervios
(Latin America), and possession (India).
• The dissociative or trance disorder is not a
normal part of a broadly accepted collective
cultural or religious practice.
Dissociative Identity Disorder
Rationale
Dissociative Identity Disorder
Rationale
A. Clarification of language, including indicating
that different states can be reported or observed,
reducing use of Dissociative Disorder Not
Otherwise Specified. Including Trance and
Possession Disorder by mentioning “experience
of possession” increases global utility.
B. Noting that amnesia for everyday events is a
common feature.
C. This criterion is included in DSM-IV Dissociative
Trance Disorder. Including it may help
differentiate normative cultural experiences from
psychopathology.
D. Addition from DSM-IV Dissociative Trance
Disorder to increase cross-cultural applicability
Specifiers:
a) A substantial proportion of patients with
Dissociative Identity Disorder have conversion
symptoms, which are related to their
dissociative disorder and require special clinical
attention and treatment.
b) Some Dissociative Identity Disorder patients
have dissociative variations in somatic
symptoms that require clarification for
differential medical diagnosis and treatment.
4
Substance-Induced Dissociative Disorder
Other Specified Dissociative Disorders
Unspecified Dissociative Disorder
• The work group has not yet proposed criteria
for this disorder.
• The work group has not yet proposed criteria
for this disorder.
＊This disorder is not listed in DSM-IV;
therefore, DSM-IV criteria for this disorder do
not exist.
＊This disorder is not listed in DSM-IV;
therefore, DSM-IV criteria for this disorder do
not exist.
• This category is for disorders in which the
predominant feature is a dissociative
symptom (i.e. a subjective loss of integration of
information or control over mental processes that,
under normal circumstances, are available to
conscious awareness or control, including
memory, identity, emotion, perception, body
representation, motor control, and behavior) that
does not meet the criteria for any specific
Dissociative Disorder.
Unspecified Dissociative Disorder
Unspecified Dissociative Disorder
Unspecified Dissociative Disorder
• Clinical presentations similar to Dissociative
Identity Disorder that fail to meet full criteria for
this disorder. Examples include presentations in
which a) there are not two or more distinct
personality states, or b) amnesia for important
personal information does not occur.
• States of dissociation that occur in individuals
who have been subjected to periods of prolonged
and intense coercive persuasion (e.g.,
brainwashing, thought reform, or indoctrination
while captive).
• Dissociative trance, characterized by narrowing
of awareness of immediate surroundings or
stereotyped behaviors or movements that are
experienced as being beyond one’s control. The
dissociative trance is not a normal part of a
broadly accepted collective cultural or religious
practice.
• Loss of consciousness, stupor, or coma not
attributable to a general medical condition.
• Ganser syndrome: the giving of approximate
answers to questions (e.g., 2 plus 2 equals 5)
when not associated with Dissociative Amnesia.
• Acute reactions to stressful events, lasting less
than one month, that are characterized by mixed
dissociative symptoms, such as
depersonalization, derealization, amnesia,
disruptions of consciousness, and/or stupor that
cause marked distress or impairment and are not
restricted to the symptoms of another mental
disorder, e.g., Acute Stress Disorder, Delirium, or
another dissociative disorder.
5
Unspecified Dissociative Disorder
• Acute states, lasting less than one month,
characterized by mixed dissociative symptoms
(e.g., amnesia, dissociative flashbacks,
disruptions of consciousness) and psychotic
symptoms (e.g., catatonia, auditory or visual
hallucinations, delusions, grossly disturbed
behavior) that cause marked distress or
impairment and do not meet criteria for Acute
Stress Disorder, a Psychotic Disorder, Delirium,
or another dissociative disorder.
6