conversation and dissociate disorder in nursing aspects and diagnosis

1. CONVERSION
AND
DISSOCIATIVE
DISORDER
By
Prof.T. Jayakumar
LNNC, LNCT
University, Bhopal

2. INTRODUCTION
HISTORY OF
CONVERSION DISORDER

3. Epidemiology
• 5% to 16% of all psychological consultation patients
manifest some conversion symptoms
• 25% to 30% of all make patients had conversion
symptoms at some time during their admission.
• Conversion disorder occurs mainly in women with a
ratio of 2:1 up to 5: 1.

4. Psychopathology
• Biological factors
• Neurophysiological factors
• Psychodynamic theory
• Transactional model

5. Types
• Dissociative motor disorder
• Dissociative sensory loss
• Dissociative hysteria

6. Clinical Features:
Motor symptoms
Involuntary movements, tics, blepharo spasm, torticoils,
seizures, abnormal gait, paralysis, faking.
Sensory symptoms
Anesthesia, midline anesthesia, blindness, tunnel vision,
deafness
Visceral symptoms
Psychogenic vomiting, pseudocyesis (false pregnancy),
diarrhea, urinary retention.

7. Diagnostic Evaluation
History Collection
Physical Examination
According To DSM IV:
• One or more symptoms - suggest neurological or
other general medical conditions.
• exacerbation of the symptom
• factitious disorder or malingering
• The symptom or deficit can not after appropriate
investigation, be fully explained
• The symptom or deficit can not after appropriate
investigation, be fully explained
• The symptom or deficit is not limited to pain or
sexual dysfunction

8. Nursing Diagnosis
1. Disturbed sensory perception related to
repressed severe anxiety
Intervention:
• Monitor ongoing assessments
• Identify gains that symptom is providing for client
• Encouraging independence and do not focus on
disability
• Encourage verbalization of fears and anxieties
• Help client recognize disability as symptom of
extreme stress
• Identity adaptive coping skills.

9. 2. Self care deficit related to loss or alteration in physical
functioning
Intervention:
• Assess client’s level of disability
• Encourage performance at level of ability
• Maintain non judgmental attitude
• Assist client as required with self care deficits
• Give positive reinforcement for independent
performance

10. DISSOCIATIVE DISORDER
• INTRODUCTION
• HISTORY

11. Types:
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Dissociative Trance Disorder
Depersonalization Disorder

12. Psychopathology
• Psychodynamic theory
• Behavioral theory
• Biological theory
• Transactional Model

13. DISSOCIATIVE AMNESIA
• Dissociative amnesia is an inability to recall
important personal information
• Usually a traumatic or stressful nature
• Extensive to be explained by ordinary
forgetfulness and is not due to the direct effects
of substance use
• Or neurological or other general medical
condition.

14. • Localized amnesia
• Selective amnesia
• Continuous amnesia
• Continuous amnesia
• Systematized amnesia

15. Diagnostic Criteria
• The predominant disturbance is one or more
episode of inability to recall Important personal
information,
• The disturbance does not occur exclusively
during the course of dissociative identity
disorder, dissociative fugue, posttraumatic
stress disorder, acute stress disorder
• The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important area of functioning.

16. Dissociative Fugue
The characteristic of dissociative fugue is a
sudden, unexpected travel away from home or
customary place of daily activities, with inability
to recall some or all of one’s past
Predisposition factors:
• A history of substance abuse
• Martial, financial or occupational stressors
• War related stressors
• Depression and suicidal ideation
• Organic disorder (temporal lobe epilepsy)

17. Diagnostic criteria
According to DSM IV – TR
• The predominant disturbance is sudden
unexpected travel away from home or place
• Inability to recall the past events
• Confusion about personal identity or assumption
of new identity
• The disturbance does not occur exclusively
during the course of dissociative phase
• The symptom cause clinically significant distress
or impairment in social, occupational other
important areas of functioning.

18. Dissociative Identity Disorder
• DID characterized by the existence or two or
more personalities in a single individual. Each
personalities is unique and composed of a
complex set of memories, behavior patterns, and
social relationships.
Predisposing factors;
• Severe child traumatic event
• Severe psychological problems
• Negative role models

19. Clinical Features
Lost time,Black outs,Wake up.
According to DSM IV – TR
• The presence of two or more distinct personality
states (each with its own relatively)
• At least two of these identities or personality
states recurrently take control of the person’s
behavior.
• Inability to recall the personal information
• The disturbance is not due to direct
physiological effects of a substance

20. Dissociative Trance
• Trance and possession disorder are
characterized by the control of person’s
personality by a spirit during the episodes.
Usually the person aware of the existence of the
other.
Clinical features
• Anxiety, Depression, physical injury.

21. Depersonalization disorder
• Depersonalization disorder is characterized by a
temporary change in the quality of self
awareness
• which often takes the form of feelings of
unreality,
• changes in body image or a sense of observing
oneself from outside the body.
Clinical features
• Anxiety, depression, obsession compulsive
thoughts, somatic complaints.

22. Diagnostic criteria
According to DSM IV – TR
Persistent or recurrent experiences of feeling
detached
• During the phase reality testing remains intact
• Clinically cause significant distress
• Does not occur exclusively during the course of
another mental disorder.

23. • Management
• General management:
• Multimodal Approach
• Behavior therapy;
• Aversion therapy- attention seeking
• Psychotherapy with abreaction
• Abreaction brings awareness and conscious,
thoughts (hypnosis, free association, and intravenous
barbiturates)
• Psychoanalysis
• Analysis the person’s personality character
• Drug therapy:
• Short term benzodiazepines – thiopentone, amytal or
diazepam

24. • NURSING PROCESS:
• Disturbed thoughts related to severe
psychological stress
• Intervention
• Obtain as much information possible from family
• Consider dislikes and likes, activities
• Do not flood the patient regarding past life.
• Identify the specific conflicts that remain
unresolved and assist client to identify possible
solutions.

25. • Inability to cope effectively with sever
anxiety
• Intervention:
• Allow the client to take as much responsibility as
possible for own self care
• Provide positive feedback
• Assist the client to set realistic goals for the
future
• Encourage the patents to participate in
supportive psychotherapy

26. • Fear or unknown circumstances
surrounding emergencies from fugue
state
• Intervention
• Maintain low level of stimuli in client’s
environment
• Observe clients behavior frequently
• Remove all dangerous objects from client’s
environment

27. • Disturbed sensory perception related to
repressed sever anxiety as evidenced by
alteration in perception.
• Intervention
• Provide support and encouragement during
times of depersonalization
• Explain the relationship between sever anxiety
and depersonalization behavior
• Explore the past experiecesand possibly
repressed painful situations

28. • Risk for suicide related to unresolved grief
• Intervention
• Assess suicidal or harmful intent. Help the client
identify stressful precipitating factors that initiate
emergence of the suicidal personality.
• Seek assistance from another strong willed
personality
• Establish trust and secure a promise that client
seek out support

29. • Lalitha,K. (2007) Mental Heath And Psychiatric
Nursing An Indian Perspective, 1st edition,
V.M.G. Book house, Bangalore,
• Bhatia M.D (2006) Essential Psychiatry, 5th
edition,CBS Publication, New Delhi,
• Sreevani (2004) A Short Text Book of
Psychiatric Nursing, 1st edition, jaypee brothers,
New Delhi,
Neeraja KP,(2008), Essentials of Mental Health
and Psychiatric Nursing, 1st edition, Jaybee
publishers, New Delhi,