TREATMENT OF AIDS-FOCUSED ILLNESS PHOBIA 425

AIDS infection',
that is, excessive worry of having
the disease despite being healthy, distraction by the
fear from daily living, constant search for signs of
the disease and for reassurance verbally and by
repeated investigations (Marks, 1987). Six of our
patients improved markedly up to three-month
follow-up, after an average of eight weeks of
treatment. Poor co-operation with exposure, because
of strength of belief, occurred in two cases: one
dropped out of treatment after early gains, in the
other case a cognitive treatment session led to
regainedimprovementin fear, avoidance and rituals.
This patient had a previous history of obsessive
compulsive disorder and he exhibited prominent
rituals during his anxiety about AIDS. While strength
of belief is not generally an indication of poor
responseto exposuretreatment in obsessive-compulsive
disorder, in some cases overvalued ideation has been
associated with treatment failure (Foa, 1979). In
cases which do not respond to adequate behavioural
treatment, a cognitive approach may be considered
(Salkovskis & Warwick, 1985).
Behavioural treatment offers hope of improvement
to non-depressed illness phobia although controlled
studies of illness phobia treatments with follow-up
have yet to be done.
References
AGRAS, W. S., SYLVFSFER,D. & OLIvEAu, D. C. (1969) The
epidemiology of common fears and phobias. Comprehensive
Psychiatry, 10, 151156.
AMERICAN PSYCHIATRIC ASSOCIATION (1987) Dk@no.s1ic and Statistical
Manual of Mental J@sorders
(3rd edn, revised)(DSMIII-R).
Washington, DC: APA.
BL@cm, G. N. (1971) The origins of disease phobia. Australia and
New Zealand Journal of Psychiatry, 5, 241-257.
FOA, E. B. (1979) Failures in treating obsessive-compulsives.
Behaviour Research and Therapy, 17, 169176.
KELLNER, R. (1985) Functional somatic symptoms and hypo
chondriasis. Archives of General Psychiatry, 42, 821-833.
MARKS, I. M. (1969) Fears and Phobias. London: Heinemann
Medical and Academic Press.
(1981) Cure and Care of Neurosis. New York: Wiley.
(1987)Fears, Phobias and Rituals. New York: Oxford
UniversityPress.
MILLER,D. (1986) AIDS, ARC and PGL. In The Management of
AIDS Patients (eds D. Miller, J. Webber & J. Green),
pp. 142-144. Basingstoke: McMillan Press.
AcroN, T. M. G. & HEDGE,B. (1988) The worried well:
their identificationand management.Journal of the Royal
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Gansr.@, J., FARMER, R., et al (1985) Pseudo-AIDS
syndrome following from fear of AIDS. British Journal of
Psychiatry, 146, 550551.
PnowsIcY, I. (1967) Dimensions of hypochondriasis. British Journal
of Psychiatry, 113, 8893.
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of obsessive-compulsive disorder - treating treatment failures.
Behavioural Psychotherapy, 13, 243-255.
WARwica,H. M. C. (1989) AIDS hypochondriasis. British Journal
of Psychiatry, 155, 125126.
& MARKS, I. M. (1988)Behaviouraltreatment of illness
phobiaand hypochondriasis.BritishJournalof Psychiatry,152,
239241.
5Stephen Logsdail, MRCP,MRCPSyCh,
Senior Registrar,
Maudsley Hospital, Denmark Hill, London SE5
8AZ, currentlyConsultantPsychiatrist,St John's
Hospital, Stone,Aylesbuiy, Buckinghamshire;Karma
Lovell, RMN, ENBCC650, Course Tutor, Psycho
logicalTreatmentUnit,MaudsleyHospital,Denmark
Hill,London 5E5 8AZ; HilaryM. C. Warwick,
MBChB, MMedSci, MRCPsych, SeniorRegictrar, Maudsley
Hospital, DenmarkHill, London 5E58AZ, currently
MRC ResearchFellow, UniversityDepartmentof
Psychiatry,WarnefordHospital, Oxford; IsaacM.
Marks, MD, FRCPsych,Professor of Experimental
Psychopathology,Institute of Psychiatry,London
*Correspondence

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
majority of patients with dissociative states seen
in India do not fit into any specific diagnostic
subcategory in the American classification system
and have to be assigned to the residual subcategory
of dissociative disorders not otherwise specified. This
study further substantiates the usefulness of suggested
subcategories - simple dissociative disorder and
possession disorder - as a large proportion of the
sample fit into these.
In contrast, the subcategorisationof these disorders
in ICD-1O appears satisfactory: 36 of the 42 cases
could be given specific diagnoses. The concept of
dividing the dissociative states according to the
prominent manifestations as well as the specificentities
included, seems largely satisfactory. However,
the individual entities have not been described
and defined with sufficient clarity, leading to
overlap and uncertainty. Dissociative stupor, trance,
movement disorder and convulsions need to be
delineated on the basis of severity of alteration
of consciousness, extent of diminution in voluntary
movements and speech, degree of responsiveness to
the environment, and the approximate duration of
each episode. Trance needs to be separated from
possession states, because the characteristic alter
ation in personal identity, which is an essential
feature of the latter, is absent in the former.
Dissociative convulsions, which were diagnosed in
31 (79%) of our sample, are especially poorly
described in lCD-b. The diagnostic guidelines do not
state whether the convulsions should be similar to
generalised tonicclonic seizures or whether they
can mimic other forms of epilepsy (e.g. absence
attacks, partial complex seizures), although this
point is clarified in the February 1990draft of lCD-b
diagnostic criteria for research. The description of
dissociative convulsions states that loss
of conscious
ness is absent or replaced by a state of stupor or
trance. In the present study, none of the cases
diagnosed as dissociative convulsions had full
consciousness during the episode. The alteration in
consciousness was similar to the state of stupor or
trance, but no guidelines are provided as to whether
these cases should be given an additional or alternative
diagnosis of stupor or trance.
The conceptual and practical usefulness of com
bining conversion and dissociative manifestations is
427
also an important issue for research, especially for
developing countries, where these states are commonly
encountered. However, since the present study
was confined to primary dissociative states, no
comments can be made on this from the results of
this study.
In conclusion, the presentstudy suggeststhat lCD
10 seems more suitable than DSMIIIR for
psychiatric out-patients presenting with primary
dissociative states in India. However, the diagnostic
guidelines for individual subcategories in ICD-lO
need to be made more explicit and specific, to avoid
overlap and uncertainty.
Acknowledgements
The authors are gratefulto Dr N. Sartoriusfor permissionto use
theICD-l0 ChapterV(F), 1989draftandtheICD-10diagnostic
criteriafor research(1990draft). Theauthorsalsothank Professor
J. E. Cooperfor his hdpful suggestionson an earlierdraft of this
paper.
References
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Manual of Mental Thsorders(3rd edn, revised)(DSM-III-R).
Washington, DC: APA.
SAXENA, S., PAcu*.uRI, R. & Wic, N. N. (1986) DSM-III
diagnostic categories for ICD-9 hysteria a study on 103 cases.
Indian Journal of Psychiatry, 2*, 47-49.
& Pa@ts@,K. V. S. R. (1989) DSM-III subclassification
of dissociativedisordersappliedto psychiatricoutpatientsin
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WIG, N. N. (1983) DSM-III: a perspective from the Third World.
InInternational
Perspectives
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J. B. W. William & A. E. Skodol). Washington, DC:
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Woaw HEALTh ORGANIZATION(1989)ChapterV, CategoriesF00-
F99,Mentaland behavioraldisorders.Clinicaldescriptionsand
diagnosticguidelines(MNH/MEP/87, 1 Rev3). International
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(draft of 10thedn)(ICD-10). Geneva:
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(1990) Chapter V, Mental and behavioral disorders.
Diagnostic criteria for research (MNH/MEP/89, 2 Rev 1).
International Classificationof Diseases(draft of 10th edn)
(ICD-10).
Geneva:WHO.
Partha Sarathi Das, MD, Pool Officer; 5Shekhar
Saxena, MD, DAB,AssociateProfessor, Department
of Psychiatry, All-India Institute of Medical
Sciences, New-Delhi-110029, India
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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