Organic Dissociative Syndrome

The article “Sleep Medications to Get Stronger Label Warnings” in the April 8 issue regarding what the FDA calls “complex sleep-related behaviors” highlights a deficiency in DSM. These behaviors include patients' “eating, driving, making phone calls, and having sex while under the influence of sleep medications.”

Fugue-like behavior secondary to an organic condition, such as the effects of sleep medication, has no suitable category in the DSM classification system. DSM's “dissociative fugue,” for example, is “not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).” In contrast, substance-induced disorders and those due to a general medical condition, as well as delirium, do not include as a central feature the apparently purposive and possibly complex or elaborate behavior seen in the kinds of cases reported in the Psychiatric News article on sleep medications and other reports over the years I have written.

I have previously proposed that DSM include a diagnostic category for such cases of what could be called “organic dissociation” or“ dissociation secondary to a general medical or substance-induced condition.” Such a category would also help classify automatisms that can be observed in conditions like temporal lobe epilepsy and dissociative-like states due to other medical factors that presently have no fitting DSM category. Not only would this category improve diagnostic precision and permit possibly greater study of these states, but also it would provide recognition of varying degrees of contribution from psychological, general medical, substance-induced, and stress-related factors, as opposed to requiring that the dissociative-like behaviors be “due to” either an organic condition alone or have no organic contribution. The dissociative-like behaviors seen in these states generally do not have an either-or etiology but rather are the expression of several determinants.