Management of dissociative disorder

Once the diagnosis of dissociative disorder has been established, the results of the clinical examination and special investigations should be discussed with the patient together with reasons for considering the symptoms to have a psychological basis. This should not be conducted in a confrontational manner. It is best to explain that the symptoms are due to stress, that they are familiar to the clinician, that serious disease has been excluded, and that full recovery can be expected. Requests for further investigations should be resisted. A reassuring and encouraging approach is beneficial. Any associated psychiatric disorder such as depression should be treated appropriately and interpersonal conflicts discussed with the patient and key relatives. These patients are often highly suggestible so they respond well to predictions of recovery. Given that they are preoccupied with physical complaints, their recovery can be assisted by providing a physical framework for improvement. Physiotherapy is particularly effective in restoring the power to a paralysed or weakened limb. Using such an approach with patients with hysterical gait disorders, about half recover completely during a three to four day hospital stay.47

In resistant cases an abreaction interview under intravenous sedation is useful. Several drugs can be used to provide the required level of sedation but benzodiazepines such as diazepam are probably the safest. During the interview the patient is encouraged to explore and ventilate any emotional problems that have hitherto not been discussed. This can have a cathartic effect and is often followed by dramatic improvement, which is facilitated if the interviewer predicts recovery before and during the interview. An interview can also be useful to clarify the diagnosis and gain access to undisclosed psychopathology. It appears particularly useful for dissociative amnesia and should be used if the memory impairment does not begin to improve within a few days of its onset. Hypnosis can be employed as an alternative procedure if the clinician has sufficient experience of the technique.

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How To Win Your War Against Anxiety Disorders

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