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Dissociative AND CONVERSION Disorder
Presented by- Dr.
PARAMPREET KAUR
Definition
• Dissociation is defined as an unconscious defense mechanism
involving the segregation of any group of mental or behavioral
processes from rest of the person’s psychic activity.
• Dissociative disorders involve this mechanism so that there is a
disruption in one or more mental functions, such as-
- memory
- identity
- perception
- consciousness
- motor behavior
• The disturbance may be -
- sudden or gradual
- transient or chronic and
- the signs and symptoms are often caused by psychological trauma.
Classification/Nosology
ICD- 10 –
• Dissociative and conversion disorders are
grouped together.
- Dissociative (conversion) disorders.
Conversion disorder
(Functional Neurological Symptom Disorder)
• Classified under somatic symptoms and Related
Disorder.
• The common theme shared by them is – partial
or complete loss of the normal integration
between memories of past, awareness of identity
and immediate sensations and control of bodily
movements.
• Presumed to be psychogenic in origin being
associated closely in time with traumatic events,
insoluble and intolerable problems or disturbed
relationship.
CLASSIFICATION OF DISSOCIATIVE
DISORDERS
ICD-10
Dissociative Disorders –
• Dissociative amnesia
• Dissociative fugue
• Dissociative stupor
• Trance and possession disorders
• Dissociative disorders of movement and
sensation
• Dissociative motor disorder
• Dissociative convulsions
• Dissociative anaesthesia and sensory
loss
• Mixed dissociative (conversion) disorder
• Other dissociative (conversion)
disorders
- Ganser’s syndrome
- multiple personality disorder
• Dissociative (conversion) disorders
unspecified
DSM-5
Dissociative Disorders –
• Dissociative Identity Disorder
• Dissociative Amnesia (specify if with
dissociative fugue)
• Depersonalization/Derealization
Disorders
• Other Specified Dissociative Disorders
• Unspecified dissociative disorder
Dissociative amnesia
• The main feature is loss of memory,
• - usually of important recent events, which is
not due to organic mental disorder and is too
extensive to be explained by ordinary
forgetfulness or fatigue. Usually centred on
traumatic events, such as accidents or
unexpected bereavements.
• Usually partial and selective.
• Extent and completeness of amnesia vary from
day to day and between investigators
• Usually centred on traumatic events, such as
accidents or unexpected bereavements.
• Usually partial and selective.
• Extent and completeness of amnesia vary from
day to day.
• Complete and generalised amnesia is rare.
• Affective states accompanying amnesia are very
varied, severe depression is rare.
• Perplexity, distress and attention seeking
behavior may be evident.
Types
• Localized amnesia –
- inability to recall events related to a circumscribed period of time.
• Selective amnesia –
- ability to remember some, but not all, of the events occurring during a
circumscribed period of time.
• Generalized amnesia –
- failure to recall one’s entire life.
• Continuous amnesia –
• - failure to recall successive events as they occur.
• Systematized amnesia –
- failure to remember a category of information, such as all memories
relating to one’s family or to a particular person
Epidemiology Of dissociative amnesia
• Reported in 2-6% of general population
• M:F = 1:1
• Generally in late adolescence and adulthood
Etiology of dissociative amnesia
• The psychosocial environment contributing to
amnesia is largely conflictual,
- patient experiences intolerable emotions of
shame, guilt, despair, rage and desperation.
• Usually results from conflicts over unacceptable
urges or impulses such as intense sexual, suicidal
or violent compulsions.
• Traumatic experiences such as physical or sexual
abuse and betrayal (betrayal trauma) induces the
disorder
Diagnosis and Clinical features
• Classic presentation –
- is an overt, florid and dramatic disturbance, quickly brought
to medical attention.
- presents with –
- intercurrent somatoform or conversion symptoms,
- alterations in consciousness,
- depersonalization, derealization, trance states,
- spontaneous age regression and anterograde dissociative
amnesia
- depression and suicidal ideation.
• Patient may have past or family history of somatoform or
dissociative symptoms
 Nonclassical presentation
- variety of symptoms such as depression or mood swings
- substance abuse
- sleep disturbances
- somatoform symptoms, anxiety and panic
- suicidal or self-mutilating impulses or acts
- violent outbursts
- eating problems and interpersonal problems
• Amnesia may also occurs for flashbacks or behavioral re-
experiencing episodes related to trauma.
DSM-5 Criteria ( Dissociative Amnesia)
A. An inability to recall important autobiographical
information, usually of traumatic or stressful nature,
that is inconsistent with ordinary forgetting.
B. Symptoms cause clinically significant distress or
impairment in social, occupational or other important
areas of functioning.
C. The disturbance is not due to the physiological effects
of a substance or neurological or medical condition
such as( transient global amnesia, head injury)
D.The disturbance is not better explained by dissociative
identity disorder, PTSD, acute stress disorder, major or
mild neurocognitive disorder).
ICD-10 Criteria
A. Amnesia either partial or complete, for
recent events that are of traumatic or
stressful nature.
B. Absence of organic brain disorders,
intoxication or excessive fatigue.
Differential Diagnosis
1. Ordinary forgetfulness (age-related cognitive decline).
2. Non pathological forms of amnesia
- infantile and childhood amnesia
- amnesia for sleep and dreaming
- hypnotic amnesia
(In dissociative amnesia, the memory loss is more extensive than non pathological amnesia)
3. Dementia, Delirium and Amnestic Disorders due to medical conditions –
• Memory loss with marked disturbance in other domains of cognitive function.
• Organic causes include –
- Korsakoff’s psychosis, CVA, postoperative and post infectious amnesia.
• ECT
4. Posttraumatic amnesia –
• A clear-cut h/o physical trauma, a period of unconsciousness or amnesia, or both.
5.Seizure disorder –
• The clinical presentation differs significantly from that of dissociative amnesia, with clear-cut ictal events and
sequelae.
• Rarely patients with CPS presents with bizarre behavior, memory problems, irritability or violence.
- telemetry or ambulatory EEG may be helpful in making diagnosis.
6.Substance related amnesia – variety of substances and intoxication can cause amnesia. Most common
agents are…
- alcohol
- sedative-hypnotic
- anticholinergic agents
- steroids
- marijuana
- hypoglycaemic agents, β– blockers
- lithium carbonate
7. Transient global amnesia (TGA)–
• Stressful life events may precede either event.
• In TGA – sudden onset of complete anterograde amnesia and learning disabilities.
- pronounced retrograde amnesia
- preservation of memory for personal identity
- overall normal behavior
- lack of gross neurological abnormalities
- rapid return of baseline cognitive function
- patient usually older than 50 yrs of age and have risk for other cerebrovascular diseases as well.
8.Dissociative identity disorder
• Multiple forms of complex amnesia including–
- recurrent blackouts
- fugues
- unexplained possessions
• - fluctuations in skills, habits and knowledge.
9.Acute stress disorder, PTSD and somatic symptom
disorder.
10.Malingering and Factitious amnesia.
Clinical features of dissociative
amnesia
• Psychophysiological symptoms
or disorders
- Asthma and breathing
problems
- perimenstrual disorders
- IBS
- GERD
- somatic memory
• Affective symptoms
- depressed mood, dysphoria or
anhedonia
- brief mood swings
- suicidal thoughts and attempts
or self mutilation
• Obsessive-compulsive
symptoms
- rumination about trauma
- washing , checking
Course and Prognosis
• Acute dissociative amnesia spontaneously resolves
once the person is removed from traumatic
circumstances.
• Chronic forms of generalized, continuous or severe
localized amnesia, which is profoundly disabled and
requires high levels of social support .
• Amnesia should be restored early to consciousness ,
otherwise the repressed memory may form a nucleus
in the unconsciousness mind around which future
amnestic episodes may develop.
Treatment
• Cognitive Therapy –
- identifying the specific cognitive distortions (trauma) may provide an entry into autobiographical
memory for which patient experiences amnesia .
• Hypnosis
- used to contain, modulate and titrate intensity of symptoms
- facilitate controlled recall of dissociated memories
- provide support and ego strengthening
- promote working through and integration of dissociated material
• Somatic Therapy –
- no known pharmacotherapy available
- pharmacologically facilitated interviews , with sodium amobarbital, thiopental, oral benzodiazepines
and amphetamines
- material uncovered in the interview needs to be processed by patient in his usual conscious state.
• Group psychotherapy –
- helpful in PTSD and in childhood abuse
- supportive interventions by the group members , may facilitate integration and mastery of the
dissociated material .
Dissociative Fugue
• Dissociative fugue is deleted as a major
diagnostic category in DSM-5 and is now
diagnosed on a subtype (specifier) of
dissociative amnesia.
• Remains a distinct identity in ICD-10.
• Dissociative fugue can be seen in both
dissociative amnesia and dissociative identity
disorder.
CONTINUATION……..
• Dissociative fugue is a sudden, unexpected travel away
from home or one’s place of daily activities.
• Person can not recall some of or all of one’s past.
• Patient may assume a new identity, usually for few
days but occasionally for long periods of time.
• After the termination of fugue, the patient may
experience perplexity, trance like behaviour,
depersonalization, derealization and conversion
symptoms in addition to Amnesia.
• Although there is amnesia for the period of fugue, the
individual’s behaviour may appear completely normal
to observer.
Etiology of dissociative fugue
• Traumatic circumstances –
- combat
- rape
- recurrent childhood sexual abuse
- massive social dislocations
- natural disasters, leading to an altered state of consciousness dominated
by a wish to flee.
• Extreme emotions or impulses –
- overwhelming fear
- guilt
- shame
- sexual, suicidal or violent urges, that are in conflict with the patient’s
conscience or ego ideals.
Epidemiology of dissociative fugue
• No systematic data exists but more common
during natural disaster, war times, major social
dislocation or violence.
• Usually described in adults.
Diagnosis of dissociative fugue
ICD-10
A. The features of dissociative amnesia
B. Purposeful travel beyond the usual every day
range
C. Maintenance of basic self-care (eating,
washing etc) and simple social interaction
with strangers (such as buying ticket or petrol,
asking directions).
Differential diagnosis
• Dissociative amnesia
• Dissociative identity
• Complex Partial Seizures
• General medical condition
• Manic phase of bipolar disorder
• Schizophrenia
• Malingering
Dissociative amnesia
• Patient may engage in
confused wandering during
an amnesia episode .
Dissociative fugue
• There is a purposeful travel
away from individual’s
home or place of daily
activities.
• usually preoccupied by a
single idea that is
accompanied by a wish to
run away.
o dissociative identity disorder patients have multiple forms of complex amnesias and
usually multiple identities.
o In Complex partial seizures –
- patient exhibit wandering or semipurposeful behavior or both during seizure or in
postictal states, for which subsequent amnesia occurs.
- history of aura, motor abnormalities, stereotyped behavior, perceptual alterations,
incontinence and postictal state
o Somatic, toxic, neurological or substance related disorders can be ruled in by history,
physical examination, laboratory tests or toxicological and drug screening
o Manic phase of bipolar disorder –
- in purposeful travel owing to mania, patient is usually preoccupied with grandiose ideas.
- often calls attention because of inappropriate behavior.
o Schizophrenia –
- memory for events during wandering episodes is difficult to ascertain owing to patient’s
thought disorder.
• A patient with dissociate fugue, do not demonstrate a psychotic thought disorder or
other symptoms of psychosis.
o Malingering of dissociative fugue can occur in individuals who are attempting to flee a
legal, financial or personal difficulty
• No test or procedures exist that distinguish true dissociative disorder from
malingering.
• Examiner should always carefully consider the diagnosis of malingering when fugue is
claimed.
D/D OF DISSOCIATIVE FUGUE
Course and Prognosis
• Most fugues are relatively brief, lasting from
hours to day.
• Most individuals recover, although refractory
dissociative amnesia may persist in rare cases.
Treatment
• Treated with an eclectic, psychodynamically oriented psychotherapy that
focuses on helping the patient recover memory for identity and recent
experience.
• Hypnotherapy and pharmacologically facilitated interviews are necessary.
Medical treatment for injuries sustained during fugue.
• Hospitalization indicated for patients with suicidal ideation or self-
destructive ideas and impulses.
• Family therapy and social interventions to resolve difficulties in family,
sexual, occupational and legal situations. When dissociative fugue involves
assumption of new identity, it is useful to conceptualize this entity as
psychologically vital to protecting the person.
- The therapeutic goal in such cases is neither suppression of the new
identity nor fascinated explication of all its attributes
Depersonalization/Derealisation
disorder
• Depersonalization is defined as the persistent or recurrent
feeling of detachment or estrangement from one’s self.
• Person may report feeling like an automaton or watching
himself in a movie .
• Derealization refers to feeling of unreality or of being
detached from one’s environment.
• Person may describe his perception of the outside world as
lacking lucidity and emotional colouring, as though
dreaming or dead.
Epidemiology
• Transient experiences of depersonalization and derealization are extremely
common
(third most common, after depression and anxiety)
• One year prevalence is 19%
• More in women (2 to 4 times) than men .
• Common in –
- seizure
- migraine
- psychedelic drugs especially marijuana, LSD and mescaline
- anticholinergics
- deep hypnosis
- mild to moderate head injury (with little or no loss of consciousness)
Depersonalization/
Derealisation
disorder
Etiology
• Psychodynamic –
- emphasized the disintegration of ego or affective response in defense of
ego.
• - explains stress or conflictual impulses as triggering events.
• Traumatic stress –
• - several studies of accident victims showed that around 60% of those
with life threatening experience reports depersonalization during the
event or immediately thereafter.
• Neurobiological theories –
- the association of depersonalization with migraine and marijuana
- favourable response to SSRIs
- implication of NMDA subtype of glutamate receptor as central to genesis of
depersonalization symptoms
DEPERSONALIZATION
/DEREALIZATION
DIAGNOSIS AND
CLINICAL FEATURES
• Patients have great difficulty in expressing
what they feels
- Express themselves as ‘I Feel dead’ , nothing
seems real or I'm standing outside of myself.
• People appear as lifeless two dimensional
‘cardboard figures’ .
Differential diagnosis
 Neurologic conditions –
- seizure disorders
- brain tumours
- postconcussive syndrome
- metabolic abnormalities
- migraine
- vertigo
- meniere disease
 Psychiatric conditions –
- panic attacks
- phobias
- PTSD
- acute stress disorder
- another dissociative disorders
-Substance intoxication or withdrawal (marijuana, cocaine)
Course and Prognosis
 Depersonalization after traumatic experiences or
intoxication remits spontaneously after removal from
traumatic circumstances or ending of the episode of
intoxication.
• Depersonalization accompanying mood, psychotic or
anxiety disorders commonly remits with definite treatment
of these conditions.
• Depersonalization disorder itself may have an episodic,
relapsing and remitting, or chronic course.
• Chronic course characterized by severe impairment in
occupational, social and personal function
Treatment
• Pharmacotherapy with SSRIs may be helpful
• Psychotherapy –
- psychodynamic, cognitive, cognitive –behavioral,
hypnotherapeutic and supportive therapy.
• Others-
- stress management strategies
- distraction techniques
- reduction of sensory stimulation
- relaxation training
- physical exercise
Dissociative Identity Disorder
• Previously called multiple personality disorder.
• Characterized by presence of two or more distinct
identities or personality states.
• The identities or personality states, sometimes called
alters, self-states, alter identities or parts.
• Symptoms of all other dissociative disorders are commonly
found in patients with dissociative identity disorder (DID) as
amnesia, fugue, depersonalization, derealization.
Epidemiology
• Female to male ratios between
5:1 to 9:1
• Strongly linked to severe experiences of early
childhood trauma (physical and sexual) .
• Preliminary studies does not found evidence of a
significant genetic contribution
ETIOLOGY
ICD- 10
• Classified in other dissociative (conversion)
disorder (F44.81)
• Disorder is rare and controversy exists about
the extent to which it is iatrogenic or culture-
specific.
Clinical features
• Key feature is the presence of 2 or more distinct personality states.
• Mental status –
- careful and detailed MSE is essential
- it is easily mistaken with schizophrenia, borderline personality
disorder or malingering.
• Memory and Amnesia symptoms –
• - enquire about experience of losing time, blackout spells and
major gaps in continuity of recall of personal information
• Dissociative alteration in identity –
- manifested by odd first-person pleural or third-person singular or
pleural self references.
- patient may refer themselves using their own first names.
Dissociative
identity
disorder……..
• The essential feature is the apparent existence
of two or more distinct personalities within an
individual, with only one of them being evident
at a time.
• Each personality is complete, with its own
memories, behavior and preferences.
• In the common form with two personalities,
one personality is usually dominant but neither
has access to the memories of the other and the
two are almost unaware of each other’s
existence.
• Change from one personality to other is usually
sudden and associated to traumatic events.
Associative symptoms
PTSD symptoms –
- intrusive symptoms
- hyperarousal
- avoidance and numbing symptoms
Somatic symptoms –
- conversion and pseudoneurological
symptoms
- seizure-like episodes
- pain symptoms
- headache, abdominal, musculoskeletal pain
- asthma and breathing problems
- perimenstrual disorders
- irritable bowel syndrome
Affective symptoms –
- depressed mood, dysphoria or anhedonia
- brief mood swings or mood lability
- suicidal thoughts and attempts of self-
mutilation
- helpless and hopeless feelings
Obsessive-Compulsive symptoms –
- ruminations about trauma
- obsessive counting, singing
- washing
- checking
Differential diagnosis
• Affective disorders
• Psychotic disorders
• Anxiety disorders
• PTSD
• Personality disorders
• Neurocognitive disorders
• Neurological and seizure disorders
• Somatic symptom disorders
• Factitious disorders
• Malingering
• Other dissociative disorders
• Deep-trance phenomena
Course and prognosis
• Limited knowledge about the natural history of untreated DID.
• Some individuals with untreated DID are thought to continue
involvement in abusive relationship or violent subcultures or both.
• Prognosis is poor in patients with comorbid organic mental
disorder, psychotic disorder, severe medical illness and refractory
substance abuse.
• Other factors that indicate poor outcome include –
- antisocial personality
- current criminal activity
- ongoing preparation of abuse
- current victimization with refusal to leave abusive relationship.
TREATMENT
• Psychotherapy
• - psychoanalytical
psychotherapy
• - cognitive therapy
• - behavioral therapy
• - hypnotherapy
• ECT--- can also be helpful
in some cases.
• Psychopharmacology
• - SSRIs for OCD
symptoms
• - mood stabilizers (more
useful for PTSD and
anxiety than mood
swings)
• - sleep problem –
mirtazapine, trazodone,
• benzodiazepines
Other Specified or Unspecified
Dissociative Disorder
• Dissociative Trance Disorder
• Ganser syndrome
• Brainwashing
• Recovered Memory Syndrome
Dissociative Trance disorder
ICD - Trance and Possession disorder (F44.3)
• Manifested by a temporary, marked alteration in the state of
consciousness or by loss of the customary sense of personal
identity without the replacement by an alternative sense of identity
.
• A variant of this, possession trance –
- involves single or episodic alterations in the state of consciousness,
characterized by the exchange of person’s customary identity with a
new identity usually attributed to a spirit, divine power, deity or
another person.
- the individual exhibits stereotypical and culturally determined
behaviors or experience being controlled by the possessing entity
- there must be partial or full amnesia for the event.
• The Trance and Possession state must not be a
normally accepted part of the cultural or religious
practice and must cause significant distress or
functional impairment in one or more of the usual
domains.
• Must not occur exclusively during the course of
psychotic disorder and is not the result of any
substance use or general medical condition .
Ganser Syndrome
• 1CD-10 , other dissociative(conversion) disorder ,
F44.80
• Described by Ganser .
• Poorly understood condition.
• Characterized by approximate answers (paralogia)
together with clouding of conscious and frequently
accompanied by hallucinations and other
dissociative, somatoform or conversion disorder
EPIDEMIOLOGY
• M:F – 2:1
• Three of the Ganser’s first
four cases were convicts,
leading to considering it
to be a disorder of penal
population and thus an
indicator of potential
malingering
ETIOLOGY
• Stress (personal and
financial problems)
• Organic brain syndromes
• Head injury
• Seizures
• Medical or Psychiatric
illness
Diagnosis and Clinical features
• The symptom of passing over (vorbeigehen) the correct answer for a related
but incorrect one , is the hallmark of Ganser syndrome.
• The approximate answer often just miss the mark but bear an obvious
relation to the question, indicating that it has been understood
- for.eg. when asked to a 25 year old woman , how old she is, replied – I'm not
5
- 2+2 = 5, green as gray .
• patient gives erroneous but comprehensible answers .
• - clouding of consciousness also occurs, manifested by disorientation,
amnesias, loss of personal information and some impairment of reality
testing.
• visual and auditory hallucinations occur in roughly half of the cases.
- neurological examination may reveal (hysterical stigmata) a nonneurological
analgesia or shifting hyperalgesia.
Differential Diagnosis
• Dementia
• Depressive pseudodementia
• The confabulation of Korsakoff’s syndrome
• Organic dysphasia's
• Reactive psychosis
Course and Prognosis
• Return to normal functions within days.
• Some cases may take month or more to
resolve.
• The individual is typically amnesic for the
period of the syndrome.
Treatment
• No systematic treatment studies have been
conducted.
• Exploration of possible stressors
• Hypnosis and amobarbital narcosynthesis, to
reveal underlying stressor
• Low dose antipsychotics.
Brainwashing
• DSM-5 describes this disorder as “identity disturbance due to
prolonged and intense coercive persuasion”.
• Mostly occurs in –
- the setting of political reform
- war imprisonment
- torture of political dissidents
- terrorist hostages.
• It implies that under conditions of adequate stress and duress,
individuals can be made to comply with the demands of those in
power, thereby undergoing major changes in their personality,
belief and behaviors.
• Person subjected to such conditions can
undergo considerable harm, including loss of
health and life and manifest a variety of
posttraumatic and dissociative symptoms.
• The first stage in coercive process has been
linked to the artificial creation of an identity
crises , with the emergence of a new
pseudoidentity that manifest a characteristics
of a dissociative symptoms
• The first stage in coercive process has been linked to
the artificial creation of an identity crises , with the
emergence of a new pseudoidentity that manifest a
characteristics of a dissociative symptoms.
• Under circumstances of extreme and malignant
dependency,
- overwhelming vulnerability and
- danger to one’s existence , individuals develop a state
characterized by – extreme idealization of their
captors, with ensuring identification with the aggressor
and externalization of their superego, regressive
adaption known as traumatic infantilism, paralysis of
will and state of frozen fright.
• Techniques used to induce such state
includes-
- isolation of the subject
- degradation
- control over all communication and basic
functions
- induction of fear and confusion
- peer pressure
- assignment of repetitive and monotonous
routines
- unpredictability of environmental supplies
- renunciation of past relationships and values
- various deprivations.
-Physical or sexual abuse, torture and extreme
sensory deprivation and neglect can be a part
of this process.
Treatment
• Depends on the background and
circumstances involved .
• exploration of preexisting psychopathology
and vulnerabilities
• general techniques used in treating
posttraumatic and dissociative states.
• Family intervention and therapy may be
required.
Recovered Memory Syndrome
• Under hypnosis or during psychotherapy, a patient may recover a
memory of a painful experience or conflict – particularly of sexual or
physical abuse .
• When the repressed material is brought back to the consciousness,
the person may recall the experience and may relive it, accompanied
by appropriate affective response (called abreaction).
• If the event recalled never really happened but the person believes it
to be true and reacts accordingly, it is known as false memory
syndrome.
 The syndrome has led to lawsuits involving accusations of child abuse
.
• Attention should be directed towards helping patients in limiting their
role as victims and transcend their past traumas.
Functional Neurological Symptom
Disorder (Conversion Disorder)
• Refers to a condition in which there are isolated
neurological symptoms that can not be explained
in terms of known mechanisms of pathology, and
in which there has been a significant
psychological stressor.
• Is an illness or deficit that affect voluntary motor
or sensory functions, which suggests another
medical condition but that is judged to be caused
by psychological factors because the illness is
preceded by conflicts or other stressors .
CONVERSION DISORDER
• The symptoms or deficits are –
- not intentionally produced
- not caused by substance use
- not limited to pain or sexual symptoms and
- the gain is primarily psychological and not
social, monetary or legal.
Epidemiology
• Reported rates vary from 11 – 300 of 100000 in general population.
• Among specific populations, the occurrence may be even higher.
• 5-15% of psychiatric consultations and 20-25% admissions involves
conversion disorders.
• Onset is generally from late childhood to early adulthood and is rare
before 10 years of age or after 35 years .
• F:M = 2:1 as much as 10:1
• Among children, an even higher predominance is seen in girls.
• RISK FACTORS-
 Recent significant stress
 Emotional trauma
 Psychiatric comorbidity
 Family history
• More common among –
- rural population
- person with little education
- those with low IQ
- low socioeconomic groups and
- military personnel who have been exposed to combat situations.
• Limited data suggests that conversion symptoms are more
frequent in relatives of people with conversion disorder.
• Increased risk in monozygotic twins has been reported .
• Symptoms are more common on left than on right side of the body
in women.
• An association exists between conversion disorder and antisocial
personality disorder in men .
Etiology
• Psychoanalytic factors –
- caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical
symptom
for eg- vaginismus protects the patient from expressing unacceptable sexual wishes.
• Learning theory –
- seen as a classically conditioned learned behavior
- symptoms of illness are learned in childhood and are expressed as a means of coping with an
otherwise impossible situation
• Biological factors –
 brain-imaging studies –
showed hypometabolism of dominant hemisphere and hypermetabolism of nondominant
hemisphere and have implicated impaired hemispheric communication .
 excessive cortical arousal sets off negative feedback loops between the cerebral cortex and the
brainstem reticular formation .
- elevated levels of corticofugal output, in turn, inhibit the patient’s awareness of bodily sensation .
Diagnosis
• DSM-5
• A. One or more symptoms of altered voluntary motor or sensory
function.
B. Clinical findings provide evidence of incompatibility between the
symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical
or mental disorder .
D. The symptom or deficit causes clinically significant distress or
impairment in social, occupational or other important areas of
functioning or warrants medical evaluation
• Specify symptom type
 With weakness or paralysis (F44.4)
 With abnormal movement (eg tremors, dystonic
movements, myoclonus, gait disorder) (F44.4)
 With swallowing symptoms (F44.4)
 With speech symptoms (eg dysphonia, slurred speech)
[F44.4]
 with attacks of seizures (F44.5)
 With anaesthesia or sensory loss (F44.6)
 With special sensory symptom (eg visual, olfactory or
hearing disturbance) [F44.6]
 With mixed symptom (F44.7)
 Can also specify with or without psychological stressor.
Clinical features
• Sensory symptoms –
- gloves and stocking anaesthesia or hemianaesthesia
beginning precisely along the midline
- all sensory modalities are involved
- can produce deafness, blindness and tunnel vision.
-distribution of disturbance is inconsistent with either central
or peripheral disease
- for eg- patient walks around without collisions or self-injury,
pupils react to light and cortical-evoked potentials are
normal.
• Motor symptoms –
- abnormal movements
- gross rhythmical tremors, choreiform movements, tics and jerks.
 gait disturbance –
- astasia-abasia, which is widely ataxic staggering gait accompanied by gross,
irregular, jerky truncal movements and thrashing and waving arm
movements .
- patient rarely fall, if they do, generally not injured .
-weakness and paralysis involving one, two or all four limbs.
- reflexes are normal, no fasciculations or muscle atrophy , electromyography
findings are normal.
• Seizure symptoms –
- pseudoseizures
tongue-biting, urinary incontinence and injuries after falling
can occur but generally not present .
- pupillary and gag reflexes are retained and no post seizures
increase in prolactin concentration.
• Other Associated Features –
• Primary gain –
• - achieve primary gain by keeping internal conflicts
outside their awareness.
• Secondary gain –
- get advantages and benefits as a result of being sick,
• for eg being excused from obligations and difficult life
situations, receiving support and assistance and
controlling other persons’ behavior.
• La Belle Indifference –
- is a patient’s cavalier attitude towards serious
symptoms
- not pathognomonic but often associated with
conversion disorder.
• Identification –
- patient may unconsciously model their
symptoms on someone important to them
(parents )
- during pathological grief reaction, bereaved
persons commonly have symptoms of the
deceased.
Differential Diagnosis
• A thorough medical and neurological work is essential in all
cases.
• It is estimated that 25-50% of patients classified as
conversion disorder eventually receives diagnosis of
neurological or neuropsychiatric medical disorder.
• Neurological disorders –
- dementia and other degenerative diseases
- brain tumors
- myasthenia gravis
- polymyositis
- multiple sclerosis
- optic neuritis
- Guillain-Barre syndrome
- neurological manifestation of AIDS
• Somatization disorder
• Hypochondriasis
• Pain disorder
• Sexual dysfunction
• Factitious disorder
• Malingering
Physical examination findings
Condition Test Conversion finding
Anaesthesia Map
dermatomes
Sensory loss does not conform to recognized
pattern of distribution.
Hemianaesthesia Check midline Strict half-body split.
Astasia-abasia Walking,
dancing
With suggestion, those who can not walk may
still be able to dance, alteration of sensory
and motor findings.
Paralysis, paresis Drop
paralyzed
hand onto
face
•Hoover test
Hand falls next to face .
Pressure noted in examiner’s hand under
paralyzed leg when attempting straight leg
raising test .
Condition Test Conversion finding
Coma • Examiner attempt
to open eyes
• ocular cephalic
maneuver
Resist opening, gaze preference is away
from doctor.
Eyes are straight ahead, do not move
from side to side .
Aphonia Request a cough Essential normal coughing sound
indicates cords are closing .
Intractable
sneezing
Observe Short nasal grunts with little or no
sneezing on inspiratory phase , minimal
facial expressions , eyes open, stops
when asleep , abates when alone .
Syncope Head-up tilt test Magnitude of changes in vital signs and
venous pooling do not explain continuing
symptoms .
Condition Test Conversion finding
Tunnel vision Visual fields Changing pattern on
multiple examinations.
Profound mononuclear
blindness
• swinging flashlight sign
(Marcus Gunn)
•Binocular visual fields
Absence of relative afferent
pupillary defect .
Sufficient vision in bad eye
precludes plotting normal
physiological blind spot in
good eye .
Severe bilateral blindness • “wiggle your fingers, I'm
just testing coordination”
•“look at your finger”
•Touch your index finger
Patient may begin to mimic
new movements before
realizing the slip.
Patient does not look there.
Even blind patients can do
this by propriception.
Course and Prognosis
• Onset is usually acute.
• Symptoms or deficit are usually of short duration
• -approximately 95% acute cases remit
spontaneously , with in 2 weeks.
• If symptoms persists for 6 months or longer, the
prognosis for symptom resolution is less than
50%.
• Recurrence occurs in ¼ to 1/5 of people within 1
year of first episode
• Good prognostic factors –
- acute onset
- short interval between onset and institution of
treatment
- above average intelligence.
 Paralysis, aphonia and blindness are associated
with good prognosis.
Tremors and seizures are poor prognostic factors .
Treatment
• Resolution is spontaneous, facilitated by insight-
oriented supportive or behavior therapy .
• Hypnosis, anxiolytics and behavioral relaxation exercise
are effective in some cases .
• Parental amobarbital or lorazepam may be helpful in
obtaining additional historic information .
• Psychodynamic approaches include psychoanalysis and
insight-oriented psychotherapy .
Epidemic hysteria
• Occasionally dissociative (or conversion) disorder spreads within a group
of people as an ‘epidemic’.
• Often happens in closed group of young women – for eg, in a girls’ school
or a nurses home . Occasionally dissociative (or conversion) disorder.
• Often anxiety has been heightened by some fear of an epidemic of
disease present in the neighbourhood.
• Typically, the epidemic starts in one person who is highly suggestible,
histrionic and a focus of attention in the group.
• The symptoms are variable but fainting and dizziness are common.
• Outbreak among school children have been documented.
• Often anxiety has been heightened by some
fear of an epidemic of disease present in the
neighbourhood.
• Typically, the epidemic starts in one person
who is highly suggestible, histrionic and a
focus of attention in the group.
• The symptoms are variable but fainting and
dizziness are common.
• Outbreak among school children have been
documented.
Dissociative Disorder final pk.pptx

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Dissociative Disorder final pk.pptx

  • 1. Dissociative AND CONVERSION Disorder Presented by- Dr. PARAMPREET KAUR
  • 2. Definition • Dissociation is defined as an unconscious defense mechanism involving the segregation of any group of mental or behavioral processes from rest of the person’s psychic activity. • Dissociative disorders involve this mechanism so that there is a disruption in one or more mental functions, such as- - memory - identity - perception - consciousness - motor behavior • The disturbance may be - - sudden or gradual - transient or chronic and - the signs and symptoms are often caused by psychological trauma.
  • 3. Classification/Nosology ICD- 10 – • Dissociative and conversion disorders are grouped together. - Dissociative (conversion) disorders.
  • 4. Conversion disorder (Functional Neurological Symptom Disorder) • Classified under somatic symptoms and Related Disorder. • The common theme shared by them is – partial or complete loss of the normal integration between memories of past, awareness of identity and immediate sensations and control of bodily movements. • Presumed to be psychogenic in origin being associated closely in time with traumatic events, insoluble and intolerable problems or disturbed relationship.
  • 5.
  • 6. CLASSIFICATION OF DISSOCIATIVE DISORDERS ICD-10 Dissociative Disorders – • Dissociative amnesia • Dissociative fugue • Dissociative stupor • Trance and possession disorders • Dissociative disorders of movement and sensation • Dissociative motor disorder • Dissociative convulsions • Dissociative anaesthesia and sensory loss • Mixed dissociative (conversion) disorder • Other dissociative (conversion) disorders - Ganser’s syndrome - multiple personality disorder • Dissociative (conversion) disorders unspecified DSM-5 Dissociative Disorders – • Dissociative Identity Disorder • Dissociative Amnesia (specify if with dissociative fugue) • Depersonalization/Derealization Disorders • Other Specified Dissociative Disorders • Unspecified dissociative disorder
  • 7.
  • 8. Dissociative amnesia • The main feature is loss of memory, • - usually of important recent events, which is not due to organic mental disorder and is too extensive to be explained by ordinary forgetfulness or fatigue. Usually centred on traumatic events, such as accidents or unexpected bereavements. • Usually partial and selective. • Extent and completeness of amnesia vary from day to day and between investigators
  • 9. • Usually centred on traumatic events, such as accidents or unexpected bereavements. • Usually partial and selective. • Extent and completeness of amnesia vary from day to day. • Complete and generalised amnesia is rare. • Affective states accompanying amnesia are very varied, severe depression is rare. • Perplexity, distress and attention seeking behavior may be evident.
  • 10. Types • Localized amnesia – - inability to recall events related to a circumscribed period of time. • Selective amnesia – - ability to remember some, but not all, of the events occurring during a circumscribed period of time. • Generalized amnesia – - failure to recall one’s entire life. • Continuous amnesia – • - failure to recall successive events as they occur. • Systematized amnesia – - failure to remember a category of information, such as all memories relating to one’s family or to a particular person
  • 11. Epidemiology Of dissociative amnesia • Reported in 2-6% of general population • M:F = 1:1 • Generally in late adolescence and adulthood
  • 12. Etiology of dissociative amnesia • The psychosocial environment contributing to amnesia is largely conflictual, - patient experiences intolerable emotions of shame, guilt, despair, rage and desperation. • Usually results from conflicts over unacceptable urges or impulses such as intense sexual, suicidal or violent compulsions. • Traumatic experiences such as physical or sexual abuse and betrayal (betrayal trauma) induces the disorder
  • 13. Diagnosis and Clinical features • Classic presentation – - is an overt, florid and dramatic disturbance, quickly brought to medical attention. - presents with – - intercurrent somatoform or conversion symptoms, - alterations in consciousness, - depersonalization, derealization, trance states, - spontaneous age regression and anterograde dissociative amnesia - depression and suicidal ideation. • Patient may have past or family history of somatoform or dissociative symptoms
  • 14.  Nonclassical presentation - variety of symptoms such as depression or mood swings - substance abuse - sleep disturbances - somatoform symptoms, anxiety and panic - suicidal or self-mutilating impulses or acts - violent outbursts - eating problems and interpersonal problems • Amnesia may also occurs for flashbacks or behavioral re- experiencing episodes related to trauma.
  • 15. DSM-5 Criteria ( Dissociative Amnesia) A. An inability to recall important autobiographical information, usually of traumatic or stressful nature, that is inconsistent with ordinary forgetting. B. Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. C. The disturbance is not due to the physiological effects of a substance or neurological or medical condition such as( transient global amnesia, head injury) D.The disturbance is not better explained by dissociative identity disorder, PTSD, acute stress disorder, major or mild neurocognitive disorder).
  • 16. ICD-10 Criteria A. Amnesia either partial or complete, for recent events that are of traumatic or stressful nature. B. Absence of organic brain disorders, intoxication or excessive fatigue.
  • 17. Differential Diagnosis 1. Ordinary forgetfulness (age-related cognitive decline). 2. Non pathological forms of amnesia - infantile and childhood amnesia - amnesia for sleep and dreaming - hypnotic amnesia (In dissociative amnesia, the memory loss is more extensive than non pathological amnesia) 3. Dementia, Delirium and Amnestic Disorders due to medical conditions – • Memory loss with marked disturbance in other domains of cognitive function. • Organic causes include – - Korsakoff’s psychosis, CVA, postoperative and post infectious amnesia. • ECT 4. Posttraumatic amnesia – • A clear-cut h/o physical trauma, a period of unconsciousness or amnesia, or both. 5.Seizure disorder – • The clinical presentation differs significantly from that of dissociative amnesia, with clear-cut ictal events and sequelae. • Rarely patients with CPS presents with bizarre behavior, memory problems, irritability or violence. - telemetry or ambulatory EEG may be helpful in making diagnosis.
  • 18. 6.Substance related amnesia – variety of substances and intoxication can cause amnesia. Most common agents are… - alcohol - sedative-hypnotic - anticholinergic agents - steroids - marijuana - hypoglycaemic agents, β– blockers - lithium carbonate 7. Transient global amnesia (TGA)– • Stressful life events may precede either event. • In TGA – sudden onset of complete anterograde amnesia and learning disabilities. - pronounced retrograde amnesia - preservation of memory for personal identity - overall normal behavior - lack of gross neurological abnormalities - rapid return of baseline cognitive function - patient usually older than 50 yrs of age and have risk for other cerebrovascular diseases as well.
  • 19. 8.Dissociative identity disorder • Multiple forms of complex amnesia including– - recurrent blackouts - fugues - unexplained possessions • - fluctuations in skills, habits and knowledge. 9.Acute stress disorder, PTSD and somatic symptom disorder. 10.Malingering and Factitious amnesia.
  • 20. Clinical features of dissociative amnesia • Psychophysiological symptoms or disorders - Asthma and breathing problems - perimenstrual disorders - IBS - GERD - somatic memory • Affective symptoms - depressed mood, dysphoria or anhedonia - brief mood swings - suicidal thoughts and attempts or self mutilation • Obsessive-compulsive symptoms - rumination about trauma - washing , checking
  • 21. Course and Prognosis • Acute dissociative amnesia spontaneously resolves once the person is removed from traumatic circumstances. • Chronic forms of generalized, continuous or severe localized amnesia, which is profoundly disabled and requires high levels of social support . • Amnesia should be restored early to consciousness , otherwise the repressed memory may form a nucleus in the unconsciousness mind around which future amnestic episodes may develop.
  • 22.
  • 23. Treatment • Cognitive Therapy – - identifying the specific cognitive distortions (trauma) may provide an entry into autobiographical memory for which patient experiences amnesia . • Hypnosis - used to contain, modulate and titrate intensity of symptoms - facilitate controlled recall of dissociated memories - provide support and ego strengthening - promote working through and integration of dissociated material • Somatic Therapy – - no known pharmacotherapy available - pharmacologically facilitated interviews , with sodium amobarbital, thiopental, oral benzodiazepines and amphetamines - material uncovered in the interview needs to be processed by patient in his usual conscious state. • Group psychotherapy – - helpful in PTSD and in childhood abuse - supportive interventions by the group members , may facilitate integration and mastery of the dissociated material .
  • 24. Dissociative Fugue • Dissociative fugue is deleted as a major diagnostic category in DSM-5 and is now diagnosed on a subtype (specifier) of dissociative amnesia. • Remains a distinct identity in ICD-10. • Dissociative fugue can be seen in both dissociative amnesia and dissociative identity disorder.
  • 25. CONTINUATION…….. • Dissociative fugue is a sudden, unexpected travel away from home or one’s place of daily activities. • Person can not recall some of or all of one’s past. • Patient may assume a new identity, usually for few days but occasionally for long periods of time. • After the termination of fugue, the patient may experience perplexity, trance like behaviour, depersonalization, derealization and conversion symptoms in addition to Amnesia. • Although there is amnesia for the period of fugue, the individual’s behaviour may appear completely normal to observer.
  • 26. Etiology of dissociative fugue • Traumatic circumstances – - combat - rape - recurrent childhood sexual abuse - massive social dislocations - natural disasters, leading to an altered state of consciousness dominated by a wish to flee. • Extreme emotions or impulses – - overwhelming fear - guilt - shame - sexual, suicidal or violent urges, that are in conflict with the patient’s conscience or ego ideals.
  • 27. Epidemiology of dissociative fugue • No systematic data exists but more common during natural disaster, war times, major social dislocation or violence. • Usually described in adults.
  • 28. Diagnosis of dissociative fugue ICD-10 A. The features of dissociative amnesia B. Purposeful travel beyond the usual every day range C. Maintenance of basic self-care (eating, washing etc) and simple social interaction with strangers (such as buying ticket or petrol, asking directions).
  • 29. Differential diagnosis • Dissociative amnesia • Dissociative identity • Complex Partial Seizures • General medical condition • Manic phase of bipolar disorder • Schizophrenia • Malingering
  • 30. Dissociative amnesia • Patient may engage in confused wandering during an amnesia episode . Dissociative fugue • There is a purposeful travel away from individual’s home or place of daily activities. • usually preoccupied by a single idea that is accompanied by a wish to run away.
  • 31. o dissociative identity disorder patients have multiple forms of complex amnesias and usually multiple identities. o In Complex partial seizures – - patient exhibit wandering or semipurposeful behavior or both during seizure or in postictal states, for which subsequent amnesia occurs. - history of aura, motor abnormalities, stereotyped behavior, perceptual alterations, incontinence and postictal state o Somatic, toxic, neurological or substance related disorders can be ruled in by history, physical examination, laboratory tests or toxicological and drug screening o Manic phase of bipolar disorder – - in purposeful travel owing to mania, patient is usually preoccupied with grandiose ideas. - often calls attention because of inappropriate behavior. o Schizophrenia – - memory for events during wandering episodes is difficult to ascertain owing to patient’s thought disorder. • A patient with dissociate fugue, do not demonstrate a psychotic thought disorder or other symptoms of psychosis. o Malingering of dissociative fugue can occur in individuals who are attempting to flee a legal, financial or personal difficulty • No test or procedures exist that distinguish true dissociative disorder from malingering. • Examiner should always carefully consider the diagnosis of malingering when fugue is claimed. D/D OF DISSOCIATIVE FUGUE
  • 32. Course and Prognosis • Most fugues are relatively brief, lasting from hours to day. • Most individuals recover, although refractory dissociative amnesia may persist in rare cases.
  • 33. Treatment • Treated with an eclectic, psychodynamically oriented psychotherapy that focuses on helping the patient recover memory for identity and recent experience. • Hypnotherapy and pharmacologically facilitated interviews are necessary. Medical treatment for injuries sustained during fugue. • Hospitalization indicated for patients with suicidal ideation or self- destructive ideas and impulses. • Family therapy and social interventions to resolve difficulties in family, sexual, occupational and legal situations. When dissociative fugue involves assumption of new identity, it is useful to conceptualize this entity as psychologically vital to protecting the person. - The therapeutic goal in such cases is neither suppression of the new identity nor fascinated explication of all its attributes
  • 34. Depersonalization/Derealisation disorder • Depersonalization is defined as the persistent or recurrent feeling of detachment or estrangement from one’s self. • Person may report feeling like an automaton or watching himself in a movie . • Derealization refers to feeling of unreality or of being detached from one’s environment. • Person may describe his perception of the outside world as lacking lucidity and emotional colouring, as though dreaming or dead.
  • 35.
  • 36. Epidemiology • Transient experiences of depersonalization and derealization are extremely common (third most common, after depression and anxiety) • One year prevalence is 19% • More in women (2 to 4 times) than men . • Common in – - seizure - migraine - psychedelic drugs especially marijuana, LSD and mescaline - anticholinergics - deep hypnosis - mild to moderate head injury (with little or no loss of consciousness) Depersonalization/ Derealisation disorder
  • 37. Etiology • Psychodynamic – - emphasized the disintegration of ego or affective response in defense of ego. • - explains stress or conflictual impulses as triggering events. • Traumatic stress – • - several studies of accident victims showed that around 60% of those with life threatening experience reports depersonalization during the event or immediately thereafter. • Neurobiological theories – - the association of depersonalization with migraine and marijuana - favourable response to SSRIs - implication of NMDA subtype of glutamate receptor as central to genesis of depersonalization symptoms DEPERSONALIZATION /DEREALIZATION
  • 39. • Patients have great difficulty in expressing what they feels - Express themselves as ‘I Feel dead’ , nothing seems real or I'm standing outside of myself. • People appear as lifeless two dimensional ‘cardboard figures’ .
  • 40. Differential diagnosis  Neurologic conditions – - seizure disorders - brain tumours - postconcussive syndrome - metabolic abnormalities - migraine - vertigo - meniere disease  Psychiatric conditions – - panic attacks - phobias - PTSD - acute stress disorder - another dissociative disorders -Substance intoxication or withdrawal (marijuana, cocaine)
  • 41. Course and Prognosis  Depersonalization after traumatic experiences or intoxication remits spontaneously after removal from traumatic circumstances or ending of the episode of intoxication. • Depersonalization accompanying mood, psychotic or anxiety disorders commonly remits with definite treatment of these conditions. • Depersonalization disorder itself may have an episodic, relapsing and remitting, or chronic course. • Chronic course characterized by severe impairment in occupational, social and personal function
  • 42. Treatment • Pharmacotherapy with SSRIs may be helpful • Psychotherapy – - psychodynamic, cognitive, cognitive –behavioral, hypnotherapeutic and supportive therapy. • Others- - stress management strategies - distraction techniques - reduction of sensory stimulation - relaxation training - physical exercise
  • 43. Dissociative Identity Disorder • Previously called multiple personality disorder. • Characterized by presence of two or more distinct identities or personality states. • The identities or personality states, sometimes called alters, self-states, alter identities or parts. • Symptoms of all other dissociative disorders are commonly found in patients with dissociative identity disorder (DID) as amnesia, fugue, depersonalization, derealization.
  • 44. Epidemiology • Female to male ratios between 5:1 to 9:1 • Strongly linked to severe experiences of early childhood trauma (physical and sexual) . • Preliminary studies does not found evidence of a significant genetic contribution ETIOLOGY
  • 45.
  • 46. ICD- 10 • Classified in other dissociative (conversion) disorder (F44.81) • Disorder is rare and controversy exists about the extent to which it is iatrogenic or culture- specific.
  • 47. Clinical features • Key feature is the presence of 2 or more distinct personality states. • Mental status – - careful and detailed MSE is essential - it is easily mistaken with schizophrenia, borderline personality disorder or malingering. • Memory and Amnesia symptoms – • - enquire about experience of losing time, blackout spells and major gaps in continuity of recall of personal information • Dissociative alteration in identity – - manifested by odd first-person pleural or third-person singular or pleural self references. - patient may refer themselves using their own first names. Dissociative identity disorder……..
  • 48. • The essential feature is the apparent existence of two or more distinct personalities within an individual, with only one of them being evident at a time. • Each personality is complete, with its own memories, behavior and preferences. • In the common form with two personalities, one personality is usually dominant but neither has access to the memories of the other and the two are almost unaware of each other’s existence. • Change from one personality to other is usually sudden and associated to traumatic events.
  • 49. Associative symptoms PTSD symptoms – - intrusive symptoms - hyperarousal - avoidance and numbing symptoms Somatic symptoms – - conversion and pseudoneurological symptoms - seizure-like episodes - pain symptoms - headache, abdominal, musculoskeletal pain - asthma and breathing problems - perimenstrual disorders - irritable bowel syndrome Affective symptoms – - depressed mood, dysphoria or anhedonia - brief mood swings or mood lability - suicidal thoughts and attempts of self- mutilation - helpless and hopeless feelings Obsessive-Compulsive symptoms – - ruminations about trauma - obsessive counting, singing - washing - checking
  • 50.
  • 51. Differential diagnosis • Affective disorders • Psychotic disorders • Anxiety disorders • PTSD • Personality disorders • Neurocognitive disorders • Neurological and seizure disorders • Somatic symptom disorders • Factitious disorders • Malingering • Other dissociative disorders • Deep-trance phenomena
  • 52. Course and prognosis • Limited knowledge about the natural history of untreated DID. • Some individuals with untreated DID are thought to continue involvement in abusive relationship or violent subcultures or both. • Prognosis is poor in patients with comorbid organic mental disorder, psychotic disorder, severe medical illness and refractory substance abuse. • Other factors that indicate poor outcome include – - antisocial personality - current criminal activity - ongoing preparation of abuse - current victimization with refusal to leave abusive relationship.
  • 53. TREATMENT • Psychotherapy • - psychoanalytical psychotherapy • - cognitive therapy • - behavioral therapy • - hypnotherapy • ECT--- can also be helpful in some cases. • Psychopharmacology • - SSRIs for OCD symptoms • - mood stabilizers (more useful for PTSD and anxiety than mood swings) • - sleep problem – mirtazapine, trazodone, • benzodiazepines
  • 54. Other Specified or Unspecified Dissociative Disorder • Dissociative Trance Disorder • Ganser syndrome • Brainwashing • Recovered Memory Syndrome
  • 55. Dissociative Trance disorder ICD - Trance and Possession disorder (F44.3) • Manifested by a temporary, marked alteration in the state of consciousness or by loss of the customary sense of personal identity without the replacement by an alternative sense of identity . • A variant of this, possession trance – - involves single or episodic alterations in the state of consciousness, characterized by the exchange of person’s customary identity with a new identity usually attributed to a spirit, divine power, deity or another person. - the individual exhibits stereotypical and culturally determined behaviors or experience being controlled by the possessing entity - there must be partial or full amnesia for the event.
  • 56. • The Trance and Possession state must not be a normally accepted part of the cultural or religious practice and must cause significant distress or functional impairment in one or more of the usual domains. • Must not occur exclusively during the course of psychotic disorder and is not the result of any substance use or general medical condition .
  • 57. Ganser Syndrome • 1CD-10 , other dissociative(conversion) disorder , F44.80 • Described by Ganser . • Poorly understood condition. • Characterized by approximate answers (paralogia) together with clouding of conscious and frequently accompanied by hallucinations and other dissociative, somatoform or conversion disorder
  • 58. EPIDEMIOLOGY • M:F – 2:1 • Three of the Ganser’s first four cases were convicts, leading to considering it to be a disorder of penal population and thus an indicator of potential malingering ETIOLOGY • Stress (personal and financial problems) • Organic brain syndromes • Head injury • Seizures • Medical or Psychiatric illness
  • 59. Diagnosis and Clinical features • The symptom of passing over (vorbeigehen) the correct answer for a related but incorrect one , is the hallmark of Ganser syndrome. • The approximate answer often just miss the mark but bear an obvious relation to the question, indicating that it has been understood - for.eg. when asked to a 25 year old woman , how old she is, replied – I'm not 5 - 2+2 = 5, green as gray . • patient gives erroneous but comprehensible answers . • - clouding of consciousness also occurs, manifested by disorientation, amnesias, loss of personal information and some impairment of reality testing. • visual and auditory hallucinations occur in roughly half of the cases. - neurological examination may reveal (hysterical stigmata) a nonneurological analgesia or shifting hyperalgesia.
  • 60. Differential Diagnosis • Dementia • Depressive pseudodementia • The confabulation of Korsakoff’s syndrome • Organic dysphasia's • Reactive psychosis
  • 61. Course and Prognosis • Return to normal functions within days. • Some cases may take month or more to resolve. • The individual is typically amnesic for the period of the syndrome.
  • 62. Treatment • No systematic treatment studies have been conducted. • Exploration of possible stressors • Hypnosis and amobarbital narcosynthesis, to reveal underlying stressor • Low dose antipsychotics.
  • 63. Brainwashing • DSM-5 describes this disorder as “identity disturbance due to prolonged and intense coercive persuasion”. • Mostly occurs in – - the setting of political reform - war imprisonment - torture of political dissidents - terrorist hostages. • It implies that under conditions of adequate stress and duress, individuals can be made to comply with the demands of those in power, thereby undergoing major changes in their personality, belief and behaviors.
  • 64. • Person subjected to such conditions can undergo considerable harm, including loss of health and life and manifest a variety of posttraumatic and dissociative symptoms. • The first stage in coercive process has been linked to the artificial creation of an identity crises , with the emergence of a new pseudoidentity that manifest a characteristics of a dissociative symptoms
  • 65. • The first stage in coercive process has been linked to the artificial creation of an identity crises , with the emergence of a new pseudoidentity that manifest a characteristics of a dissociative symptoms. • Under circumstances of extreme and malignant dependency, - overwhelming vulnerability and - danger to one’s existence , individuals develop a state characterized by – extreme idealization of their captors, with ensuring identification with the aggressor and externalization of their superego, regressive adaption known as traumatic infantilism, paralysis of will and state of frozen fright.
  • 66. • Techniques used to induce such state includes- - isolation of the subject - degradation - control over all communication and basic functions - induction of fear and confusion - peer pressure
  • 67. - assignment of repetitive and monotonous routines - unpredictability of environmental supplies - renunciation of past relationships and values - various deprivations. -Physical or sexual abuse, torture and extreme sensory deprivation and neglect can be a part of this process.
  • 68. Treatment • Depends on the background and circumstances involved . • exploration of preexisting psychopathology and vulnerabilities • general techniques used in treating posttraumatic and dissociative states. • Family intervention and therapy may be required.
  • 69. Recovered Memory Syndrome • Under hypnosis or during psychotherapy, a patient may recover a memory of a painful experience or conflict – particularly of sexual or physical abuse . • When the repressed material is brought back to the consciousness, the person may recall the experience and may relive it, accompanied by appropriate affective response (called abreaction). • If the event recalled never really happened but the person believes it to be true and reacts accordingly, it is known as false memory syndrome.  The syndrome has led to lawsuits involving accusations of child abuse . • Attention should be directed towards helping patients in limiting their role as victims and transcend their past traumas.
  • 70. Functional Neurological Symptom Disorder (Conversion Disorder) • Refers to a condition in which there are isolated neurological symptoms that can not be explained in terms of known mechanisms of pathology, and in which there has been a significant psychological stressor. • Is an illness or deficit that affect voluntary motor or sensory functions, which suggests another medical condition but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors .
  • 71.
  • 72.
  • 73. CONVERSION DISORDER • The symptoms or deficits are – - not intentionally produced - not caused by substance use - not limited to pain or sexual symptoms and - the gain is primarily psychological and not social, monetary or legal.
  • 74. Epidemiology • Reported rates vary from 11 – 300 of 100000 in general population. • Among specific populations, the occurrence may be even higher. • 5-15% of psychiatric consultations and 20-25% admissions involves conversion disorders. • Onset is generally from late childhood to early adulthood and is rare before 10 years of age or after 35 years . • F:M = 2:1 as much as 10:1 • Among children, an even higher predominance is seen in girls. • RISK FACTORS-  Recent significant stress  Emotional trauma  Psychiatric comorbidity  Family history
  • 75. • More common among – - rural population - person with little education - those with low IQ - low socioeconomic groups and - military personnel who have been exposed to combat situations. • Limited data suggests that conversion symptoms are more frequent in relatives of people with conversion disorder. • Increased risk in monozygotic twins has been reported . • Symptoms are more common on left than on right side of the body in women. • An association exists between conversion disorder and antisocial personality disorder in men .
  • 76. Etiology • Psychoanalytic factors – - caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom for eg- vaginismus protects the patient from expressing unacceptable sexual wishes. • Learning theory – - seen as a classically conditioned learned behavior - symptoms of illness are learned in childhood and are expressed as a means of coping with an otherwise impossible situation • Biological factors –  brain-imaging studies – showed hypometabolism of dominant hemisphere and hypermetabolism of nondominant hemisphere and have implicated impaired hemispheric communication .  excessive cortical arousal sets off negative feedback loops between the cerebral cortex and the brainstem reticular formation . - elevated levels of corticofugal output, in turn, inhibit the patient’s awareness of bodily sensation .
  • 77.
  • 78. Diagnosis • DSM-5 • A. One or more symptoms of altered voluntary motor or sensory function. B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. C. The symptom or deficit is not better explained by another medical or mental disorder . D. The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation
  • 79. • Specify symptom type  With weakness or paralysis (F44.4)  With abnormal movement (eg tremors, dystonic movements, myoclonus, gait disorder) (F44.4)  With swallowing symptoms (F44.4)  With speech symptoms (eg dysphonia, slurred speech) [F44.4]  with attacks of seizures (F44.5)  With anaesthesia or sensory loss (F44.6)  With special sensory symptom (eg visual, olfactory or hearing disturbance) [F44.6]  With mixed symptom (F44.7)  Can also specify with or without psychological stressor.
  • 80.
  • 81. Clinical features • Sensory symptoms – - gloves and stocking anaesthesia or hemianaesthesia beginning precisely along the midline - all sensory modalities are involved - can produce deafness, blindness and tunnel vision. -distribution of disturbance is inconsistent with either central or peripheral disease - for eg- patient walks around without collisions or self-injury, pupils react to light and cortical-evoked potentials are normal.
  • 82. • Motor symptoms – - abnormal movements - gross rhythmical tremors, choreiform movements, tics and jerks.  gait disturbance – - astasia-abasia, which is widely ataxic staggering gait accompanied by gross, irregular, jerky truncal movements and thrashing and waving arm movements . - patient rarely fall, if they do, generally not injured . -weakness and paralysis involving one, two or all four limbs. - reflexes are normal, no fasciculations or muscle atrophy , electromyography findings are normal.
  • 83. • Seizure symptoms – - pseudoseizures tongue-biting, urinary incontinence and injuries after falling can occur but generally not present . - pupillary and gag reflexes are retained and no post seizures increase in prolactin concentration.
  • 84.
  • 85. • Other Associated Features – • Primary gain – • - achieve primary gain by keeping internal conflicts outside their awareness. • Secondary gain – - get advantages and benefits as a result of being sick, • for eg being excused from obligations and difficult life situations, receiving support and assistance and controlling other persons’ behavior. • La Belle Indifference – - is a patient’s cavalier attitude towards serious symptoms - not pathognomonic but often associated with conversion disorder.
  • 86. • Identification – - patient may unconsciously model their symptoms on someone important to them (parents ) - during pathological grief reaction, bereaved persons commonly have symptoms of the deceased.
  • 87. Differential Diagnosis • A thorough medical and neurological work is essential in all cases. • It is estimated that 25-50% of patients classified as conversion disorder eventually receives diagnosis of neurological or neuropsychiatric medical disorder. • Neurological disorders – - dementia and other degenerative diseases - brain tumors - myasthenia gravis - polymyositis - multiple sclerosis - optic neuritis - Guillain-Barre syndrome - neurological manifestation of AIDS
  • 88. • Somatization disorder • Hypochondriasis • Pain disorder • Sexual dysfunction • Factitious disorder • Malingering
  • 89. Physical examination findings Condition Test Conversion finding Anaesthesia Map dermatomes Sensory loss does not conform to recognized pattern of distribution. Hemianaesthesia Check midline Strict half-body split. Astasia-abasia Walking, dancing With suggestion, those who can not walk may still be able to dance, alteration of sensory and motor findings. Paralysis, paresis Drop paralyzed hand onto face •Hoover test Hand falls next to face . Pressure noted in examiner’s hand under paralyzed leg when attempting straight leg raising test .
  • 90. Condition Test Conversion finding Coma • Examiner attempt to open eyes • ocular cephalic maneuver Resist opening, gaze preference is away from doctor. Eyes are straight ahead, do not move from side to side . Aphonia Request a cough Essential normal coughing sound indicates cords are closing . Intractable sneezing Observe Short nasal grunts with little or no sneezing on inspiratory phase , minimal facial expressions , eyes open, stops when asleep , abates when alone . Syncope Head-up tilt test Magnitude of changes in vital signs and venous pooling do not explain continuing symptoms .
  • 91. Condition Test Conversion finding Tunnel vision Visual fields Changing pattern on multiple examinations. Profound mononuclear blindness • swinging flashlight sign (Marcus Gunn) •Binocular visual fields Absence of relative afferent pupillary defect . Sufficient vision in bad eye precludes plotting normal physiological blind spot in good eye . Severe bilateral blindness • “wiggle your fingers, I'm just testing coordination” •“look at your finger” •Touch your index finger Patient may begin to mimic new movements before realizing the slip. Patient does not look there. Even blind patients can do this by propriception.
  • 92. Course and Prognosis • Onset is usually acute. • Symptoms or deficit are usually of short duration • -approximately 95% acute cases remit spontaneously , with in 2 weeks. • If symptoms persists for 6 months or longer, the prognosis for symptom resolution is less than 50%. • Recurrence occurs in ¼ to 1/5 of people within 1 year of first episode
  • 93. • Good prognostic factors – - acute onset - short interval between onset and institution of treatment - above average intelligence.  Paralysis, aphonia and blindness are associated with good prognosis. Tremors and seizures are poor prognostic factors .
  • 94. Treatment • Resolution is spontaneous, facilitated by insight- oriented supportive or behavior therapy . • Hypnosis, anxiolytics and behavioral relaxation exercise are effective in some cases . • Parental amobarbital or lorazepam may be helpful in obtaining additional historic information . • Psychodynamic approaches include psychoanalysis and insight-oriented psychotherapy .
  • 95. Epidemic hysteria • Occasionally dissociative (or conversion) disorder spreads within a group of people as an ‘epidemic’. • Often happens in closed group of young women – for eg, in a girls’ school or a nurses home . Occasionally dissociative (or conversion) disorder. • Often anxiety has been heightened by some fear of an epidemic of disease present in the neighbourhood. • Typically, the epidemic starts in one person who is highly suggestible, histrionic and a focus of attention in the group. • The symptoms are variable but fainting and dizziness are common. • Outbreak among school children have been documented.
  • 96. • Often anxiety has been heightened by some fear of an epidemic of disease present in the neighbourhood. • Typically, the epidemic starts in one person who is highly suggestible, histrionic and a focus of attention in the group.
  • 97. • The symptoms are variable but fainting and dizziness are common. • Outbreak among school children have been documented.