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

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-10

Dissociative amnesia

Dissociative fugue

Dissociative stupor

Trance and possession disorders

Dissociative motor disorders

Dissociative convulsions

Dissociative anesthesia and sensory loss

Mixed dissociative disorders

Other dissociative disorders

Dissociative disorder, unspecified

Table 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 department

Conversion disorder presenting as motor or sensory symptoms

Dissociative convulsions

Hyperventilation

Dissociative amnesia

Dissociative fugue

acute stress reaction

Possession states

Grief reaction presenting as a dissociative symptom

Concurrent 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 emergencies

Studies 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 episode

Non-Psychiatric differentials	Psychiatric differentials
Epilepsy	Posttraumatic stress disorder
Transient global amnesia
Post encephalitic amnesia	Acute stress disorder
Korsakoff amnestic syndrome	Psychotic disorders
Post-traumatic amnesia due to brain injury	Substance-related amnesia
	Depressive disorders
Stoke	Anxiety disorders
Multiple sclerosis	Dementia
Systemic lupus erythematosus	Delirium
Movement disorders	Somatoform disorder
Myasthenia gravis	Factitious disorders
Poliomyelitis
Periodic paralysis
Other neurocognitive disorders
Malingering

The 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 disorders

Guiding questions for the assessment of dissociative disorders
Does the clinical presentation suggest a differential of dissociative disorders?
What is the specific type of dissociation disorder?
Could a physical disorder explain the set of symptoms?
Could a psychiatric disorder explain the set of symptoms?
Are there any associated psychiatric co-morbidities?

History 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]

Localized amnesia

Loss of memory related to events during a specific period

Selective amnesia

Loss of memory related to some events but not all occurring during a circumscribed period of time

Generalized amnesia

Loss of memory about one’s entire life

Continuous amnesia

Loss of memory of events one after another sequentially

Systematized amnesia

Loss of Memory of certain specific events such as all memories relating to one’s family or a particular person

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 disorders

Dissociative amnesia	Dissociative Fugue	Dissociative Motor disorders	Dissociative anesthesia Sensory loss	Dissociative stupor	Dissociative convulsions	Trans and possession
Inability to recall recent events, Usually that of personal importance	An apparently purposeful journey away from home or workplace along with loss of memory of the event	A complete or partial loss of ability to move one or more than one limb	A complete or partial Sensory loss in one or more modalities	A decrease or absence of voluntary movement and responsiveness to external stimuli.	Movements that resemble epileptic seizures	A partial or complete loss of sense of awareness of one’s surroundings along with loss of one’s identity.

Clinical 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 disorders

Symptom/ Disorder	Differentiating features
Forgetfulness	Unrelated to trauma or stress, memory loss is less extensive
Delirium	Disturbances in sensorium, disorientation, perceptual disturbances, medical etiology.
Dementia	Many cognitive domains are affected. Autobiographical memory was affected late in the course. Psychobehavioral symptoms present
Substance use disorder	History of substance use present, amnesia, and/or travel is associated with the time of abuse of the substance.
Acute stress disorder and PTSD	May coexist with dissociative amnesia. Other features of ASD and PTSD are seen.
Schizophrenia	Memory loss may occur during an acute episode However, delusions and hallucinations and usually present. Wandering and travel may also occur. Often the person calls attention to himself or her self-owing to inappropriate behavior.
Somatoform disorders	Can present with sensory motor symptoms similar to dissociative disorders; however, the former is a chronic illness that begins early in life and includes symptoms in many other organ systems

Clinical 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 convulsions

Favoring epilepsy	Favouring dissociative convulsions
Pre-ictal
Unrelated to stressful events	Precipitated by stressful events
Sleep: occurs in physiological sleep	Usually, occurs while awake
Occur even when alone	Mostly around people
Frequently preceded by the presence of an aura	Not preceded by an aura
Ictal
Gradual occurrence	Sudden occurrence >2 min, frequently variable.
Duration: <2 min, generally fixed	The patient’s speech is coherent and the tone is usually sad
Patients speech is incoherent and consists of monotonous,	Present
meaningless phrases, or sounds (epileptic cry)	Pupils appear normal Inconsistent increase in heart rate
Head rotation movements: Absent
Pupils are dilated with altered reaction time	Urinary incontinence is extremely rare
Consistent increased heart rate	Tongue bite is usually on tip of the tongue
Urinary incontinence commonly occurs	Eyes closed usually
Tongue bites usually on the lateral side Eyes mostly open	Focal neurological deficits do not occur Rug burns or excoriations due to vigors movement are more
Focal neurological deficits can occur	common
Fractures or ecchymoses due to falls are seen
Post Ictal
Recovery is gradual with postictal amnesia and headache common	Recovery is sudden with postictal amnesia and headache not seen.

Amnesia 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 pertaining to the symptoms of dissociative disorders, some of the questions are outlined in Table 9 below. It can also be done in a structured manner in the form of scales [Table 10]. It is important to note that along with these questions, the importance of a comprehensive mental status examination should not be de-emphasized.[15]

Table 9.

Important interview questions to elicit dissociative symptoms

Interview questions

Do you ever experience blackouts, blank spells, or memory lapses?

Have you found yourself to have lost time that you cannot explain?

Do people tell you about the behavior you exhibited that you are unable to remember?

Do you ever find yourself far away from your home or workplace and not know how you got there?

Do you find objects in your possession that you do not remember ever having?

Do you find that your objects are missing or not in their usual place?

Do you have thoughts or feelings that are not in your control or not yours? Do they come from inside or outside you?

Table 10.

Various assessment tools available for screening dissociative disorders[15]

Scales	Type	No. of questions
Dissociative Experience Scale	Self-report	28 items
Somatoform Dissociation Questionnaire	Self-report	20 items
Somatoform Dissociation Questionnaire-5	Self-report	5 items
Peritraumatic Dissociative Experiences Questionnaire (PDEQ)	Self-report	10 items
Cambridge Depersonalization Scale (CDS)	Self-report	29 items
Clinician-Administered Dissociative States Scale	Clinician administered	28 items
Multidimensional Inventory of Dissociation	Self-report	218 items

Clinical examination

A thorough head-to-toe examination is as important as a good clinical history while evaluating a suspected case of dissociative disorder in the ED. The examination should focus on ruling out the primary medical causes enlisted above as well as gathering information in support of a dissociative etiology.

The bedside neurological exam is the core element used to make a diagnosis of dissociative disorders, especially those of dissociative motor and/or sensory symptoms. Examination findings can often be subtle and warrant practice to avoid misdiagnosis; thus, the specificity of signs may be reduced in individuals showing “marginally” positive signs or when performed by clinicians who have more limited expertise. A systematic and narrative review by Daum et al.[20] evaluated many signs for functional neurological symptoms, they found that 14 have been validated, these tend to have low sensitivity but a high specificity value that suggests that even though they are not always present in patients with functional symptoms when positive they help into “RULE IN” dissociative disorders. These along with their descriptions are mentioned in Table 11.

Table 11.

Clinical signs during neurological examination to ‘rule in’ dissociative disorders

Functional disorder	Test	Description
Motor symptoms	Hoover sign	After the patient lies in a supine position, the examiner puts his hand under the heel of the non-paralyzed leg and instructs the patient to try lifting the paralyzed leg. Sign (-) ve if downward pressure is exerted by the non-paralyzed leg on the examiner’s hand Sign (+) ve no pressure is exerted by the non-paralyzed leg on the examiner’s hand. Sign (+) ve indicated a dissociative cause
	Abductor sign	After the patient lies in a supine position, the examiner puts both hands on the lateral side of the patient’s legs and puts adducting pressure equally with both hands. The patient is told to abduct the non-paralyzed leg while the examiner observes the movement of the paralyzed leg. Sign is (-) ve if the paralyzed leg moves towards the midline Sign is (+) ve if the paralyzed leg stays in the Same position Sign (+) vs indicates dissociative etiology
	Abductor finger sign	The patient sits on a chair resting both forearms on board and suspending hands in the air. The patient is instructed to abduct the fingers of the non-paralytic hand for 2 min against the resistance provided by the examiner’s hand. Sign (-) ve if the paralytic hand remains in the same position Sign (+) vs if the paralytic hand also abducts due to synergy. Sign (+) ve indicates dissociative etiology
	Spinal injury test	After the patient lies in the supine position, the examiner lifts the patient’s knees on the bed and then releases the knees gently Sign (-) ve if the legs become straight Sign (+) ve if the knees remain lifted Sign (+) vs indicates dissociative etiology
	Collapsing/give-away weakness	In dissociative motor disorders, the limb initially provides resistance to light touch but then suddenly gives away and collapses.
	Co-contraction	Observation during muscle strength testing (or with surface electromyogram) Sign(+) ve if simultaneous contraction of agonist and antagonist results in no/little movement
	Motor inconsistency	In dissociative disorders, some moments of a muscle group are possible, whereas other movements of the same muscle group are impaired
Sensory Symptoms	Midline splitting	Dissociative cause is more likely if there is an exact splitting of sensation in the midline
	Splitting of vibration	Dissociative disorder is more likely if a difference is found in the sensation of a tuning fork placed over the left compared to the right side of the sternum or frontal bone
	Nonanatomical sensory loss	Dissociative disorder is more likely if the Diminished sensation fits a ‘non-dermatomal pattern’ distribution
	Inconsistency/changing pattern of sensory loss	In dissociative disorders, the sensory loss is generally inconsistent and non-reproducible on repeated sensory testing
Gait symptoms	Dragging monoplegic gait	In dissociative disorders, during walking, the paralyzed leg instead of performing a circumduction is dragged at the hip behind the body.
	Chair test	If the patient is able to propel a swivel chair better than walking then a dissociative cause is more likely.

Investigations

Because a large number of medical disorders can present with dissociative symptoms, the investigations that can be done on an emergency basis are limited, they are alluded to in Table 12 presented below.[15]

Table 12.

Advisable investigations in emergency settings while evaluating dissociative disorders

EEG-to rule out seizure disorders

CT scan of head/MRI brain-to rule out structural lesions of the brain

Drug urine screening to rule out substance use disorder

Serum prolactin to rule out seizure disorder

Complete blood count, blood sugar levels, and serum electrolytes to rule out physical disorders

MANAGEMENT

Generally, the main goal of treatment in dissociative/conversion disorders is improvement in the patient’s adaptive functioning via psychotherapy techniques focusing on the stressors rather than the dissociative episodes. However, an acute dissociative episode, especially in those with a hitherto undiagnosed illness, can be an extremely harrowing experience for the patient as well as their family members. Apart from this, certain cases can also present a considerable risk of harm to self or others. Hence, in emergency settings, the most important goals for management are safety and symptom reduction. Table 13 outlines the key principles to be remembered for the same:

Table 13.

Key principles of management of psychiatric emergencies in dissociative disorders

Key principles of management of psychiatric emergencies in dissociative disorders

Ensure the safety of the patient, the bystanders as well as your own

Avoid confronting patients in the ED with the opinion that the symptom is of psychological origin as this is likely to hinder the formation of a therapeutic alliance.

Judicious but thorough investigative workup and referral to rule out a primary medical cause of presenting symptoms.

Avoid unnecessary evaluation of symptoms as it can lead to fixation on symptoms and hinder treatment

Remember that diagnosis of dissociative/conversion disorder is not based on negative medical workup since both can co-exist not so infrequently.

A flow chart for the management of dissociative disorders presenting in the ED has been summarized in Figure 2.

Figure 2.

Outline of management of acute dissociative episode presenting in emergency settings

Establishing safety

The foremost task when a dissociative disorder presents acutely to the ED is to establish the safety of the patient and/or surrounding people, followed by symptom reduction.[21] Table 14 covers the points to be ensured for the same.

Table 14.

Important points while establishing safety in an acute presentation of dissociative disorder

Establishing safety during an acute presentation of dissociative disorder in the ED

Always remain calm and reassuring.

Isolate the patient, preferably in a separate quiet room.

Ask the family members and/or the bystanders to leave the room unless their presence is specifically warranted.

Ensure that the environment is free of sharps or any potentially harmful substances

Monitor airway, breathing, and circulation (in case of an acute dissociative convulsion attack).

Avoid administering noxious stimuli (such as ether inhalation or sternal pressure) in case of a stuporous/unresponsive patient.

In case of marked excitation/agitation with risk of harm to self/others, use verbal de-escalation techniques to calm down the patient. However, keep nursing staff on standby for physical/chemical restraining in case verbal de-escalation fails.

Always ensure your own safety as well as that of others.

Stay with the patient till the symptoms begin to improve.

Establishing a therapeutic alliance

The establishment of a good rapport and therapeutic alliance with both the patient and family members is fundamental for successful treatment. This makes it easier for the family members to understand the doctor’s point of view, particularly in cases where their behaviors and interactions with the patient have a contributory role in the disorder. Similarly, a compassionate understanding of patients’ and their caregivers’ perceptions of the symptoms is also important.

Employing relaxation techniques

In patients who present with acute conversion symptoms such as hyperventilation or a dissociative convulsion attack, relaxation techniques targeting the anxiety such as slow, deep breathing can help in reducing the intensity of the attack and thereby help in early termination. Calm and precise instructions along with verbal suggestions to the patient go a long way over medications in causing a reduction of the symptoms.

Using grounding techniques

Patients with dissociative disorders and a history of trauma often experience acute dissociative episodes characterized by a subjective feeling of emotional numbing, depersonalization, and flashbacks of the traumatic past secondary to ongoing stress or anxiety. Sometimes, a patient may present to the ED in such a state, even if the present situation no longer poses any kind of danger.

Grounding techniques are designed to connect the patient back to reality and the present moment, thereby reducing the intensity of the dissociative (trance, depersonalization, etc.) episode. With practice, it also helps in preventing such spontaneous episodes, including the switches in dissociative identity disorder (DID). The techniques employ simple instructions to improve the patient’s sensory awareness (awareness of the body’s position using any of the five senses) or cognitive awareness (awareness of themselves and the place/people around them) of the present moment.[22] The details are mentioned in Table 15.

Table 15.

Important grounding techniques that can be used in emergency settings

Grounding techniques that can be used in the ED

Improving sensory awareness:

Asking the patient to focus on the sound of a clock or the doctor’s voice (auditory)

Asking the patient to identify 10 colors in the room (visual)

Making the patient hold an easily accessible palm-sized object in their hand (touch)

Improving cognitive awareness:

Orienting the patient to name, age, day, date, and location

Talking through

At times when dissociative trance/possession disorders are in an acute spell or patients with multiple personality (dissociative identity) disorder present switches, they can present to the ED in a state of acute excitement/agitation. In such cases, instead of resorting to the more aggressive methods of physical or chemical restraining, it is possible to tide through the acute situation merely by compassionate listening and talking directly to the possessing entity/personality system. This involves acknowledging the personality system, directly addressing the internal conflict, and emphasizing the need of working together to ensure good adaptive functioning. Similarly, in the case of the possession spell, a balance of modern techniques and culture-specific traditional approaches frequently may be required. This involves acknowledging the ‘entity,’ listening to its needs and then persuading it to leave the body. For this, a non-judgmental acceptance of the patient’s/caregiver’s perception of the symptoms is paramount.

Pharmacological management

Due to varied clinical presentations frequently overlapping with medical conditions and a tendency of patients/caregivers to resort to more traditional methods of treatment (e.g., faith healers, shamans), very few studies have been able to systematically investigate the pharmacological management of dissociative disorders in an acute setting. Apart from this, no psychotropic medications have been specifically recommended or have been found to be useful for the management of dissociative disorders, unless there is a presence of comorbid psychiatric conditions such as depression or anxiety disorder.

For the management of dissociative disorders in emergency settings, benzodiazepines and antipsychotics have been the most used psychotropic agents based on data available from case series and open-label studies.[23]

For treatment of acute anxiety associated with a dissociative/conversion episode, benzodiazepines (BZDs) such as lorazepam (2 mg) and clonazepam (0.5 mg) can be administered per orally (PO). In cases where immediate action is warranted, as in the case of acute agitation, lorazepam 2 mg can be administered intramuscularly (IM) or intravenously (IV), with repeat dosing in 30 min if required.

In cases of severe psychotic agitation/excitement, particularly when the distinction between a primary psychotic disorder and dissociative disorder may be unclear, IM haloperidol up to a dose of 5 mg can be administered along with promethazine 25 mg can be administered. If required, the dose may be repeated after 1 to 2 hours.

Coadministration of IM haloperidol 5 mg with lorazepam 2 mg may have an additive calming effect, but with a higher chance of sedation.

Unless the diagnosis of dissociative convulsion is unclear, empirical antiepileptics are not recommended after an acute non-epileptic seizure attack.

Importantly, it must be noted that excessive reliance on PO benzodiazepine preparations (such as sublingual formulations) for managing every acute episode can promote a secondary gain in the patient. Similarly, in cases of patients with established/clear diagnoses of dissociative disorders who come to emergency services in an acute attack, the family members should be tactfully explained that medications are neither required nor approved for dissociative symptoms. Otherwise, the caregivers may perceive that the doctor is unable to diagnose/treat the presenting illness. Moreover, unnecessary reliance on medications may lead to the patient/family members losing their focus on the non-pharmacological modalities of treatment due to the belief that the medications will cure the dissociative/conversion symptoms.

However, in some cases, administration of a placebo with verbal suggestions may also be required to ensure proper follow-up of the patient and caregivers for further sessions, particularly in those with poor psychological awareness, poor support system, and in those insisting on medications.

Psychoeducation

Psychoeducation of family members forms a crucial part of the management even in acute settings. Efficient communication about the nature of the disorder and its symptoms and the role of establishing trust and ensuring follow-up for treatment. Key points have been mentioned in Table 16.[24]

Table 16.

Key points to be conveyed to caregivers during psychoeducation regarding dissociative disorders

Key points to be conveyed during psychoeducation

Acknowledging and reinforcing the genuineness of the presenting symptoms.

Explaining that the presence of symptoms in the absence of a physical illness is common.

Using metaphors to describe the functional/psychological nature of symptoms, for example, similar to a “software rather than a hardware problem” and that the symptoms occur when the “computer crashes” can be helpful in conveying the nature of the illness.

Explaining the relationship between the mind and body and how stress and emotions can lead to physical manifestations, for example, physical manifestations of anxiety

Reassuring that the symptoms are not dangerous or life-threatening (except in cases involving self-harm or harm to others) Instructing family members to avoid promoting secondary gain during an acute episode

Highlighting the importance of psychological treatment focusing on stressors in reducing the frequency/intensity of dissociative symptoms, managing stress, and improving the adaptive functioning of the patient.

Conveying the role of medical treatment as only for comorbid depression or anxiety.

Promoting a hopeful sentiment of improvement with proper treatment using available approaches

Determination of further management plan

Once the acute symptoms have subsided in the ED, a plan for further management can then be formulated. For detailed evaluation, planning further psychotherapeutic approaches, and managing interpersonal conflicts, the choice of treatment setting between OPD and indoor management has to be decided upon. Hospitalization is recommended in certain situations as mentioned in Table 17.[25] Otherwise, the patient can be asked to follow up on an OPD basis for further treatment.

Table 17.

Indications for hospitalization in dissociative disorder presenting as a psychiatric emergency

Indications for indoor treatment of dissociative disorder presenting as a psychiatric emergency

Unclear diagnosis (possibility of an underlying primary medical cause for symptoms or clarification of complex psychopathology) Risk of harm to self (self-mutilation or persistent suicidal ideations) or others

Presence of overwhelming dissociative/conversion symptoms causing significant disability Severe perceived disability by family members Presence of medical co-morbidities requiring intensive monitoring and treatment

Progressive worsening of the clinical picture due to poor adherence to treatment or a recent crisis in patient’s life

CONCLUSION

This CPG explores the variety of ways in which dissociative disorders can present in an emergency setting and provides approaches toward their diagnosis and acute management. There may be a significant overlap between the presentation of dissociative disorders and medical illnesses (especially neurological) in emergency settings. A detailed history exploring the semiology of the episodes, temporal relation with stressful events, comorbid psychiatric illnesses, and a thorough clinical examination is important to differentiate the same. In many cases, certain investigations may be required before reaching a clear diagnosis. Due to the presence of co-morbid psychiatric illnesses and the associated psychosocial stressors, a holistic management plan that includes psychotropics, as well as psychosocial interventions, may be required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.