TREATMENT OF AIDS-FOCUSED ILLNESS PHOBIA 425

AIDS infection',
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cases which do not respond to adequate behavioural phobiaand hypochondriasis.BritishJournalof Psychiatry,152,
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Classification of Dissociative States in DSMIIIR

and ICD1O
(1989 Draft)
A Study of Indian Out-patients

PARTHA SARATHI DAS and SHEKHAR SAXENA

When 42 casesof primarydissociativestatesfrom subcategories, which, however, needto be defined and

India were classified according to DSM-IIi-R and described more explicitly.
1CD-1O criteria, DSM-IIl-R was found to be unsatis British
JournalofPsychiatry(1991),159,425427
factory, with 40 (95.2%) casesreceivinga diagnosis
of dissociative cNsordernot otherwise specified. The
majority fit well into simple dissociative and possession The classification of dissociative disorders has
disorders. ICD-1O was found to be more satisfactory, undergone major change in recent years. DSMIII
with 36 (85.5%) patIents fitting into specific initiated this process by splitting hysteria into
426 DAS AND SAXENA

somatoform and dissociative disorders, and DSM Table 1

III-R has endorsed this without any major changes Diagnosticsubcategoriesfor 42 Indian patients with
(American Psychiatric Association, 1987). The DSM dissociativestates
classification for these categories has generally been Subcategoryn%DSM-lll-RMultiple
welcomed as apositivedevelopment, but criticisms have
also been made about several aspects. For instance,
the coexistence of conversion and dissociative states disorder00Psychogenic
personality
in a substantial proportion of patients frequently fugue00Psychogenic
amnesia00Depersonalisation
leads to a double diagnosis (Saxena et al, 1986). It disorder25Dissociative
has also been suggested that DSM subcategories of specified4095simple
disorder
nototherwise
dissociative disorders cover only those entities which disorder13481possession
dissociative
are relatively well known to American psychiatrists, disorder125CD-laDissociative
without mentioning a number of states which are
frequently encountered in other parts of the world amnesia00Dissociative
(Wig, 1983). One study showed that a large majority fugue00Dissociative
of cases with dissociative states seen in India had to stupor00Trance
disorders410Dissociative
andpossession
be given the diagnosis of atypical dissociative disorders12Dissociative
movement
disorder, in the absence of any other suitable convulsions3174Dissociative
subcategory in DSM-III (Saxena & Prasad, 1989). loss00Mixedanaesthesia
andsensory
This study also suggested the inclusion of two disorders00Other
dissociative
andconversion
additional subcategories - simple dissociative disorder disorders410Dissociative
dissociative and conversion
and possession disorder- in the classification system. unspecified00Not
andconversion
disorder,
subcategory(depersonalisation
fittingintoany
Chapter V (F) of ICDlO(April, 1989 draft) states)25
(World Health Organization, 1989), which is still
provisional, has also completely reorganised the 1. Suggested subcategories (Saxena & Pissed, 1989).
classification of hysteria, and has created categories
under somatoform disorders that are similar to the 42 casesfor the final analysis.The DSM-III-R and lCD
DSM categories. But ICD-1O has still kept dis 10 diagnoseswere made on these cases using specified
sociative and conversion symptoms together under diagnosticcriteria and diagnostic guidelinesrespectively.
F-44 and has subdivided this category according to
the most prominent manifestations. Subcategories Resufts
for stupor, trance and possession states, and
There were36 womenand 6 men. Twenty-fourwereaged
convulsion have been included. This approach 20 yearsor younger, 11were2130
years, and 7 wereover
appears to obviate some of the shortcomings of 30. Twenty-oneweremarriedand 33 had receivedsome
DSM-III-R, especially for use in developing countries. formal education.
However, we are not aware of any study which has The DSMIIIR
(axis I) diagnoses for these cases are
compared the suitability of these two classificatory given in Table 1. The 40 cases classified under dissociative
systems on a series of cases with dissociative states. disorders
nototherwise
specified
werefurther
assessed
The present paper reports data on 42 cases with applyingthecriteriafor suggestedsubcategoriesof simple
dissociative states seen in India with the aim of dissociative disorder and possession disorder (Saxena &
comparing the suitability of DSM-III-R and ICD-1O Prasad, 1989). These categories fit 34 and 2 cases
respectively.
forthesecases.
The lCD-b diagnosisfor thesecasesarealso givenin
Table 1. Two caseswith depersonalisationstatesdid not
Method fitintoany subcategoryof dissociative
disorders.
Evidence for psychological causation (traumatic events,
Case records of all the 1517 patients seen in the adult insolubleand intolerableproblemsor disturbedrelation
psychiatryout-patientclinicof the AIIMS Hospitalduring ships)wasdefinitelypresentin 16,probablypresentin 12,
1987 were screened for dissociative symptoms. These andabsent in14cases (the
diagnoses
forthese
14werekept
symptoms were defined according to the DSM1IIRprovisional). These cases were well distributed among the
description of disturbanceor alteration in the normally various subcategories.
integrative functions of identity, memory or consciousness.
Seventy-eight(5.14lo)
such cases were detected. These
case records were jointly reviewed by both the authors. Discussion
Records with inadequate information (10) and those which
showed presence of any additional diagnosis besides The present study corroborates the findings of an
dissociativedisorder(26)wereexcludedat this stage,leaving earlier study (Saxena & Prasad, 1989), that the
 CLASSIFYING DISSOCIATIVE STATES IN INDIAN OUT-PATIENTS 427
majority of patients with dissociative states seen also an important issue for research, especially for
in India do not fit into any specific diagnostic developing countries, where these states are commonly
subcategory in the American classification system encountered. However, since the present study
and have to be assigned to the residual subcategory was confined to primary dissociative states, no
of dissociative disorders not otherwise specified. This comments can be made on this from the results of
study further substantiates the usefulness of suggested this study.
subcategories - simple dissociative disorder and In conclusion, the presentstudy suggeststhat lCD
possession disorder - as a large proportion of the 10 seems more suitable than DSMIIIR for
sample fit into these. psychiatric out-patients presenting with primary
In contrast, the subcategorisationof these disorders dissociative states in India. However, the diagnostic
in ICD-1O appears satisfactory: 36 of the 42 cases guidelines for individual subcategories in ICD-lO
could be given specific diagnoses. The concept of need to be made more explicit and specific, to avoid
dividing the dissociative states according to the overlap and uncertainty.
prominent manifestations as well as the specificentities
included, seems largely satisfactory. However, Acknowledgements
the individual entities have not been described
and defined with sufficient clarity, leading to The authors are gratefulto Dr N. Sartoriusfor permissionto use
overlap and uncertainty. Dissociative stupor, trance, theICD-l0 ChapterV(F), 1989draftandtheICD-10diagnostic
criteriafor research(1990draft). Theauthorsalsothank Professor
movement disorder and convulsions need to be J. E. Cooperfor his hdpful suggestionson an earlierdraft of this
delineated on the basis of severity of alteration paper.
of consciousness, extent of diminution in voluntary
movements and speech, degree of responsiveness to References
the environment, and the approximate duration of
AME@CANPSYQuAT@CASSOQA1TON
(1987) Diagnastk w@ StatLstkal
each episode. Trance needs to be separated from Manual of Mental Thsorders(3rd edn, revised)(DSM-III-R).
possession states, because the characteristic alter Washington, DC: APA.
ation in personal identity, which is an essential SAXENA, S., PAcu*.uRI, R. & Wic, N. N. (1986) DSM-III
feature of the latter, is absent in the former. diagnostic categories for ICD-9 hysteria a study on 103 cases.
Indian Journal of Psychiatry, 2*, 47-49.
Dissociative convulsions, which were diagnosed in & Pa@ts@,K. V. S. R. (1989) DSM-III subclassification
31 (79%) of our sample, are especially poorly of dissociativedisordersappliedto psychiatricoutpatientsin
described in lCD-b. The diagnostic guidelines do not India.American Journalof Psychiatry,146,261-262.
state whether the convulsions should be similar to WIG, N. N. (1983) DSM-III: a perspective from the Third World.
InInternational
Perspectives
on DSM-III (edsR. L. Spitzer,
generalised tonicclonic seizures or whether they J. B. W. William & A. E. Skodol). Washington, DC:
can mimic other forms of epilepsy (e.g. absence APA.
attacks, partial complex seizures), although this Woaw HEALTh ORGANIZATION(1989)ChapterV, CategoriesF00-
point is clarified in the February 1990draft of lCD-b F99,Mentaland behavioraldisorders.Clinicaldescriptionsand
diagnostic criteria for research. The description of diagnosticguidelines(MNH/MEP/87, 1 Rev3). International
Classificationof Di.seases
(draft of 10thedn)(ICD-10). Geneva:
dissociative convulsions states that loss
of conscious WHO.
ness is absent or replaced by a state of stupor or (1990) Chapter V, Mental and behavioral disorders.
trance. In the present study, none of the cases Diagnostic criteria for research (MNH/MEP/89, 2 Rev 1).
diagnosed as dissociative convulsions had full International Classificationof Diseases(draft of 10th edn)
(ICD-10).
Geneva:WHO.
consciousness during the episode. The alteration in
consciousness was similar to the state of stupor or Partha Sarathi Das, MD, Pool Officer; 5Shekhar
trance, but no guidelines are provided as to whether Saxena, MD, DAB,AssociateProfessor, Department
these cases should be given an additional or alternative of Psychiatry, All-India Institute of Medical
diagnosis of stupor or trance. Sciences, New-Delhi-110029, India
The conceptual and practical usefulness of com
bining conversion and dissociative manifestations is aCo@espondence
Classification of dissociative states in DSM-III-R and ICD-10 (1989
draft). A study of Indian out-patients.
P S Das and S Saxena
BJP 1991, 159:425-427.
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