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解離性障害

著者: 吉益晴夫 埼玉医科大学総合医療センター

監修: 上島国利 昭和大学

著者校正済:2021/11/24
現在監修レビュー中
患者向け説明資料

概要・推奨   

  1. 安心できる安全な環境が確保されていない場合は、環境を調整する。(推奨度1)
  1. 解離性障害に適用のある薬はない。症状に合わせて慎重に薬物療法を行う。(推奨度3)
  1. 併存する精神疾患があれば、併存する精神疾患に対する薬物療法を行う。(推奨度2)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
吉益晴夫 : 特に申告事項無し[2021年]
監修:上島国利 : 原稿料(大日本住友製薬)[2021年]

改訂のポイント:
  1. ICD-11で新たに追加された分類として、部分的解離性同一性障害と複雑性PTSDについて加筆修正を行った。

病態・疫学・診察

疾患情報  
  1. 解離とは防衛機制の1つである:
  1. 自己を守るために、極度に不快な体験を意識から切り離すものである。
  1. 生活上の刺激に対して簡単に解離が出現し、生活に支障が生じるようになると解離性障害と診断される。
  1. 解離性障害の基本的特徴:
  1. 解離性障害の基本的特徴は、意識、記憶、同一性、または知覚についての通常は統合されている機能の破綻である。
  1. 障害は突然に生じることも、徐々に生じることもある。
  1. また、一過性のことも慢性のこともある[1]
  1. 解離性(転換性)障害が共有する共通の主題:
  1. 解離性(あるいは転換性)障害が共有する共通の主題は、過去の記憶、同一性と直接的感覚、および身体運動のコントロールの間の正常な統合が部分的にあるいは完全に失われることである(ICD-10)。
  1. 解離性障害の分類:
  1. 解離性健忘、解離性同一性障害、他の特定される解離性障害があり、DSM-5ではそれに加えて離人感・現実感消失性障害が、ICD-10では転換性障害を含むところが相違点である。
  1. ICD-11の解離性障害は、解離性健忘、解離性同一性障害、トランス障害、憑依トランス障害に、離人感・現実感消失性障害、部分的解離性同一性障害が加わり、診断名がカバーする範囲が広がっている。
  1. 解離性とん走は解離性健忘に含める。
  1. 解離性障害の症状:
  1. 記憶に問題が生じて健忘を来すもの(解離性健忘)、健忘に場所の移動と自己アイデンティティ喪失を伴うもの(解離性とん走)、複数の交替人格が出現するもの(解離性同一性障害)、意識を失って倒れてしまうもの(他の特定される解離性障害に分類される)が代表的である。
  1. 診断名の歴史的変遷:
  1. 従来の心因性健忘が現在は解離性健忘となり、多重人格が現在は解離性同一性障害と呼ばれている。
  1. また、解離性健忘が過去の全生活史に及んだ場合には、全生活史健忘と呼ぶこともある。
  1. ヒステリーという用語は現在では使用されていないが、解離性障害を含む概念である。
  1. 神経症も幅の広い病態を含む用語であり、神経症圏内などという言い方をした場合に解離性障害もそのなかに含まれる。
 
  1. 解離性障害の患者数は少なくない(推奨度2)。
  1. 精神科外来患者82例における解離性障害の頻度を調べた米国の報告では解離性障害を29%(24例)で認め、内訳は、解離性健忘10%、他の特定される解離性障害9%、解離性同一性障害6%、離人感・現実感消失性障害5%、解離性とん走0%であった[2]
  1. 精神科外来患者150例における解離性障害の割合を調べたトルコの研究によると、解離性障害は12%のケースで認められた。内訳は、解離性同一性障害4%、他の特定される解離性障害8%であった[3]
  1. ニューヨーク州郊外の住人658人における、過去1年間の解離性障害有病率は9.1%(24例)であった。内訳は、離人感・現実感消失性障害0.8%、解離性健忘1.8%、解離性同一性障害1.5%、他の特定される解離性障害5.5%であった[4]
問診・診察のポイント  
  1. 過去の記憶に問題があるので本人から十分な情報が得られないことがある:
  1. 解離性健忘のために過去の出来事を想起できないことがある。

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文献 

著者: Brad Foote, Yvette Smolin, Margaret Kaplan, Michael E Legatt, Deborah Lipschitz
雑誌名: Am J Psychiatry. 2006 Apr;163(4):623-9. doi: 10.1176/appi.ajp.163.4.623.
Abstract/Text OBJECTIVE: The purpose of the study was to assess the prevalence of DSM-IV dissociative disorders in an inner-city outpatient psychiatric population.
METHOD: Subjects were 231 consecutive admissions (84 men and 147 women, mean age=37 years) to an inner-city, hospital-based outpatient psychiatric clinic. The subjects completed self-report measures of dissociation (Dissociative Experiences Scale) and trauma history (Traumatic Experiences Questionnaire). Eighty-two patients (35%) completed a structured interview for dissociative disorders (Dissociative Disorders Interview Schedule).
RESULTS: The 82 patients who were interviewed did not differ significantly on any demographic measure or on the self-report measures of trauma and dissociation from the 149 patients who were not interviewed. Twenty-four (29%) of the 82 interviewed patients received a diagnosis of a dissociative disorder. Dissociative identity disorder was diagnosed in five (6%) patients. Compared to the patients without a dissociative disorder diagnosis, patients with a dissociative disorder were significantly more likely to report childhood physical abuse (71% versus 27%) and childhood sexual abuse (74% versus 29%), but the two groups did not differ significantly on any demographic measure, including gender. Chart review revealed that only four (5%) patients in whom a dissociative disorder was identified during the study had previously received a dissociative disorder diagnosis.
CONCLUSIONS: Dissociative disorders were highly prevalent in this clinical population and typically had not been previously diagnosed clinically. The high prevalence of dissociative disorders found in this study may be related to methodological factors (all patients were offered an interview rather than only those who had scored high on a screening self-report measure) and epidemiological factors (extremely high prevalence rates for childhood physical and sexual abuse were present in the overall study population).

PMID 16585436  Am J Psychiatry. 2006 Apr;163(4):623-9. doi: 10.1176/ap・・・
著者: V Sar, H Tutkun, B Alyanak, B Bakim, I Baral
雑誌名: Compr Psychiatry. 2000 May-Jun;41(3):216-22. doi: 10.1016/S0010-440X(00)90050-6.
Abstract/Text The aim of this study was to determine the frequency of dissociative disorders among psychiatric outpatients in Turkey. One hundred fifty consecutive outpatients admitted to the psychiatry clinic of a university hospital were screened with the Dissociative Experiences Scale (DES). Twenty-three patients (15.3%) with a DES score greater than 30 and a comparison group selected from the same outpatient population who scored less than 10 on the scale were then interviewed with the Dissociative Disorders Interview Schedule (DDIS) in a blind fashion. According to the DDIS, 18 patients (12.0%) received a diagnosis of dissociative disorder; 83.3% (n = 15) of the dissociative patients reported neglect, 72.2% (n = 13) emotional abuse, 50.0% (n = 9) physical abuse, and 27.8% (n = 5) sexual abuse during childhood. Dissociative disorders are not rare among psychiatric outpatients. Self-rating instruments and structured interviews can be used successfully for screening dissociative disorders, which are usually underrecognized. Neglect was the most frequently reported type of childhood trauma, suggesting the importance of other childhood experiences in addition to sexual and/or physical abuse in the development of dissociative psychopathology.

PMID 10834631  Compr Psychiatry. 2000 May-Jun;41(3):216-22. doi: 10.10・・・
著者: Jeffrey G Johnson, Patricia Cohen, Stephanie Kasen, Judith S Brook
雑誌名: J Psychiatr Res. 2006 Mar;40(2):131-40. doi: 10.1016/j.jpsychires.2005.03.003. Epub 2005 Dec 6.
Abstract/Text OBJECTIVE: To investigate the association of dissociative disorder (DD) with impaired functioning and co-occurring Axis I and personality disorders among adults in the community.
METHOD: Psychiatric interviews were administered to a sample of 658 adult participants in the Children in the Community Study, a community-based longitudinal study.
RESULTS: Depersonalization disorder (prevalence: 0.8%), dissociative amnesia (prevalence: 1.8%), dissociative identity disorder (prevalence: 1.5%), and dissociative disorder not otherwise specified (prevalence: 4.4%), evident within the past year, were each associated with impaired functioning, as assessed by the clinician-administered Global Assessment of Functioning Scale. These associations remained significant after controlling for age, sex, and co-occurring disorders. Individuals with anxiety, mood, and personality disorders were significantly more likely than individuals without these disorders were to have DD, after the covariates were controlled. Individuals with Cluster A (DD prevalence: 58%), B (DD prevalence: 68%), and C (DD prevalence: 37%) personality disorders were substantially more likely than those without personality disorders were to have DD.
CONCLUSIONS: DD is associated with clinically significant impairment among adults in the community. DD may be particularly prevalent among individuals with personality disorders.

PMID 16337235  J Psychiatr Res. 2006 Mar;40(2):131-40. doi: 10.1016/j.・・・
著者: E M Bernstein, F W Putnam
雑誌名: J Nerv Ment Dis. 1986 Dec;174(12):727-35.
Abstract/Text Dissociation is a lack of the normal integration of thoughts, feelings, and experiences into the stream of consciousness and memory. Dissociation occurs to some degree in normal individuals and is thought to be more prevalent in persons with major mental illnesses. The Dissociative Experiences Scale (DES) has been developed to offer a means of reliably measuring dissociation in normal and clinical populations. Scale items were developed using clinical data and interviews, scales involving memory loss, and consultations with experts in dissociation. Pilot testing was performed to refine the wording and format of the scale. The scale is a 28-item self-report questionnaire. Subjects were asked to make slashes on 100-mm lines to indicate where they fall on a continuum for each question. In addition, demographic information (age, sex, occupation, and level of education) was collected so that the connection between these variables and scale scores could be examined. The mean of all item scores ranges from 0 to 100 and is called the DES score. The scale was administered to between 10 and 39 subjects in each of the following populations: normal adults, late adolescent college students, and persons suffering from alcoholism, agoraphobia, phobic-anxious disorders, posttraumatic stress disorder, schizophrenia, and multiple personality disorder. Reliability testing of the scale showed that the scale had good test-retest and good split-half reliability. Item-scale score correlations were all significant, indicating good internal consistency and construct validity. A Kruskal-Wallis test and post hoc comparisons of the scores of the eight populations provided evidence of the scale's criterion-referenced validity.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 3783140  J Nerv Ment Dis. 1986 Dec;174(12):727-35.
著者: Brad Foote, Jane Park
雑誌名: Curr Psychiatry Rep. 2008 Jun;10(3):217-22.
Abstract/Text Schizophrenia and dissociative identity disorder (DID) are typically thought of as unrelated syndromes--a genetically based psychotic disorder versus a trauma-based dissociative disorder--and are categorized as such by the DSM-IV. However, substantial data exist to document the elevated occurrence of psychotic symptoms in DID; awareness of these features is necessary to prevent diagnostic confusion. Recent research has also pointed out that schizophrenia and DID overlap not only in psychotic symptoms but also in terms of traumatic antecedents, leading to a number of suggestions for revision of our clinical, theoretical, and nosologic understanding of the relationship between these two disorders.

PMID 18652789  Curr Psychiatry Rep. 2008 Jun;10(3):217-22.
著者: R P Kluft
雑誌名: Am J Psychiatry. 1987 Mar;144(3):293-8. doi: 10.1176/ajp.144.3.293.
Abstract/Text Thirty patients with multiple personality disorder had one or more of Schneider's 11 first-rank symptoms at initial assessment (mean = 3.6; range = 1-8). The author describes these symptom categories, eight of which were noted in the patients he interviewed, and illustrates them from the patients' case material. He suggests that inquiry about first-rank symptom phenomena may be a valuable diagnostic clue to the presence of multiple personality disorder.

PMID 3826426  Am J Psychiatry. 1987 Mar;144(3):293-8. doi: 10.1176/aj・・・
著者: Rachel Yehuda, Charles W Hoge, Alexander C McFarlane, Eric Vermetten, Ruth A Lanius, Caroline M Nievergelt, Stevan E Hobfoll, Karestan C Koenen, Thomas C Neylan, Steven E Hyman
雑誌名: Nat Rev Dis Primers. 2015 Oct 8;1:15057. doi: 10.1038/nrdp.2015.57. Epub 2015 Oct 8.
Abstract/Text Post-traumatic stress disorder (PTSD) occurs in 5-10% of the population and is twice as common in women as in men. Although trauma exposure is the precipitating event for PTSD to develop, biological and psychosocial risk factors are increasingly viewed as predictors of symptom onset, severity and chronicity. PTSD affects multiple biological systems, such as brain circuitry and neurochemistry, and cellular, immune, endocrine and metabolic function. Treatment approaches involve a combination of medications and psychotherapy, with psychotherapy overall showing greatest efficacy. Studies of PTSD pathophysiology initially focused on the psychophysiology and neurobiology of stress responses, and the acquisition and the extinction of fear memories. However, increasing emphasis is being placed on identifying factors that explain individual differences in responses to trauma and promotion of resilience, such as genetic and social factors, brain developmental processes, cumulative biological and psychological effects of early childhood and other stressful lifetime events. The field of PTSD is currently challenged by fluctuations in diagnostic criteria, which have implications for epidemiological, biological, genetic and treatment studies. However, the advent of new biological methodologies offers the possibility of large-scale approaches to heterogeneous and genetically complex brain disorders, and provides optimism that individualized approaches to diagnosis and treatment will be discovered.

PMID 27189040  Nat Rev Dis Primers. 2015 Oct 8;1:15057. doi: 10.1038/n・・・
著者: Ruth A Lanius, Eric Vermetten, Richard J Loewenstein, Bethany Brand, Christian Schmahl, J Douglas Bremner, David Spiegel
雑誌名: Am J Psychiatry. 2010 Jun;167(6):640-7. doi: 10.1176/appi.ajp.2009.09081168. Epub 2010 Apr 1.
Abstract/Text In this article, the authors present evidence regarding a dissociative subtype of PTSD, with clinical and neurobiological features that can be distinguished from nondissociative PTSD. The dissociative subtype is characterized by overmodulation of affect, while the more common undermodulated type involves the predominance of reexperiencing and hyperarousal symptoms. This article focuses on the neural manifestations of the dissociative subtype in PTSD and compares it to those underlying the reexperiencing/hyperaroused subtype. A model that includes these two types of emotion dysregulation in PTSD is described. In this model, reexperiencing/hyperarousal reactivity is viewed as a form of emotion dysregulation that involves emotional undermodulation, mediated by failure of prefrontal inhibition of limbic regions. In contrast, the dissociative subtype of PTSD is described as a form of emotion dysregulation that involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions. Both types of modulation are involved in a dynamic interplay and lead to alternating symptom profiles in PTSD. These findings have important implications for treatment of PTSD, including the need to assess patients with PTSD for dissociative symptoms and to incorporate the treatment of dissociative symptoms into stage-oriented trauma treatment.

PMID 20360318  Am J Psychiatry. 2010 Jun;167(6):640-7. doi: 10.1176/ap・・・
著者: Ketil J Oedegaard, Dag Neckelmann, Franco Benazzi, Vigdis E G Syrstad, Hagop S Akiskal, Ole Bernt Fasmer
雑誌名: J Affect Disord. 2008 Jun;108(3):207-16. doi: 10.1016/j.jad.2007.10.018. Epub 2008 Feb 20.
Abstract/Text BACKGROUND: Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders.
METHODS: The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya;s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour.
RESULTS: Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n=30) and without an affective temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7 vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was still significant (p=0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder (n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions (n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p=0.043).
LIMITATIONS: The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status.
CONCLUSIONS: Dissociative symptoms measured with the Dissociative Experience Scale are associated with bipolar features, using formal DSM-IV criteria, cyclothymic temperament and the speed and impatience subscale of the JAS.

PMID 18077000  J Affect Disord. 2008 Jun;108(3):207-16. doi: 10.1016/j・・・
著者: V J Felitti, R F Anda, D Nordenberg, D F Williamson, A M Spitz, V Edwards, M P Koss, J S Marks
雑誌名: Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8.
Abstract/Text BACKGROUND: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.
METHODS: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.
RESULTS: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.
CONCLUSIONS: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

PMID 9635069  Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s074・・・
著者: Julie P Gentile, Kristy S Dillon, Paulette Marie Gillig
雑誌名: Innov Clin Neurosci. 2013 Feb;10(2):22-9.
Abstract/Text There is a wide variety of what have been called "dissociative disorders," including dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, and forms of dissociative disorder not otherwise specified. Some of these diagnoses, particularly dissociative identity disorder, are controversial and have been questioned by many clinicians over the years. The disorders may be under-diagnosed or misdiagnosed, but many persons who have experienced trauma report "dissociative" symptoms. Prevalence of dissociative disorders is unknown, but current estimates are higher than previously thought. This paper reviews clinical, phenomenological, and epidemiological data regarding diagnosis in general, and illustrates possible treatment interventions for dissociative identity disorder, with a focus on psychotherapy interventions and a review of current psychopharmacology recommendations as part of a comprehensive multidisciplinary treatment plan.

PMID 23556139  Innov Clin Neurosci. 2013 Feb;10(2):22-9.

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