Medical undergraduate lecture 2008

1. Dr Zahiruddin Othman
3rd December 2008

2. Epidemic Hysteria
In epidemic (communicable) or mass hysteria there is
often background of tension in an institution, an initial
symptoms appear in an influential figure and spread to
others by suggestion

3. HystericalorHistrionic
PersonalityDisorder
Hysterical
(hystrionic)
behavior is
consciously
motivated,
unlike the
unconscious
motivation
underlying
symptoms in
dissociative
(conversion)
disorders

4. HystericalPsychosis
Berserkers (or Berserks) were Norse
warriors who wore coats of wolf or bear skin
and who were commonly understood to
have fought in an uncontrollable rage or
trance of fury, hence the modern word
berserk

5. St Louis hysteria
[Briquet’s syndrome]
a.k.a. somatization disorder, and refers to
individuals with recurrent and multiple
unexplained physical symptoms
commencing before the age of 30 years
and of chronic duration

6. Hysteria
Dissociation
Conversion
Somatoform
Mental symptoms
without organic
cause
Physical
symptoms without
organic cause
Neurological
symptoms without
organic cause
ICD-10
Hysterical Neurosis

7. ICD-10
F44 Dissociative
[conversion] disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and
sensory loss
F44.7 Mixed dissociative [conversion]
disorders
F44.8 Other dissociative [conversion]
disorders
.80 Ganser’s syndrome
.81 Multiple personality disorder
.82 Transient dissociative
[conversion] disorder occuring in
childhood and adolescent
Somatoform Disorders
Somatoform disorder
Conversion disorder
Pain disorder
Hypochondriasis
Body dysmorphic disorder
Dissociative disorders
Dissoc. Amnesia
Dissoc. Fugue
Dissoc. Identity Disorder
Depersonalization disorder
DSM-IV

8. Professor Charcot (left) of Paris'
Salpêtrière demonstrates hypnosis on a
"hysterical" patient, "Blanche" (Marie)
Wittman, who is supported by Dr.
Joseph Babiński.
DISSOCIATION, HYPNOSIS AND THE
UNCONSCIOUS
Hypnosis raise into consciousness
those mental elements are rendered
unconscious
Amnesias, trance states, and variety
of localized paralyses, anaesthesias,
paraesthesias, and hallucinations
induced by hypnosis were
indistinguishable from those occurring
symptomatically in hysteric patients
Persons with dissociative disorders
have a high degree of hypnotizability

9. Deficit Model [Janet]
Pathological poverty or
deficiency of the basic
mental energy that
enable a healthy person
to combine the various
mental functions
(sensation, volition,
memories) into a stable,
unified psychological
structure under the
conscious domination
and control of self or ego

10. Conflict Model [Freud]
Ego vigorously
protect itself from
psychological pain
trough the operation
of the defensive
mechanism of
repression – a
process manifested
phenomenologically
as dissociation
Aztec Mask: The Three Faces of Life

11. Dissociative Amnesia
• The severity of loss of memory (partial or
complete) for recent events of traumatic or
stressful nature contrasts with the
otherwise very good preservation of other
cognitive functions and the individual’s
ability to utilize memory that are not of a
personal nature
• DDx: transient global amnesia

12. Dissociative Fugue
• Features of dissociative amnesia +
purposeful travel beyond the usual
everyday range and maintenance of basic
self-care. Simple social interactions with
strangers are usually preserved.
• Loss of personal identity and of one’s
entire past life, by assumption of a new
identity.

13. Betty is a waitress in a diner,
who pours coffee behind her
back while her eyes are glued
to her favorite soap opera A
Reason to Love. She has no
idea that her husband is selling
drugs at his car dealership, that
he is having an affair with his
secretary, or that he intends on
leaving Betty.
Betty witnesses the murder and
experiences a fugue state, escaping the
reality of murder into the comforting fantasy
of the soap opera. In her mind, she
assumes the identity of one of the
characters in the daytime drama, a nurse.

14. Dissociative Identity Disorder
• There exist within the
person 2 or more distinct
personalities or personality
states, at least 2 of which
recurrently take full control
of the person’s behavior.
• The alters are separated by
a varying degree of an
amnestic barrier.

15. The Three Faces of Eve [1957]
Eve White is a quiet, self-effacing
wife and mother who has headaches
and occasional blackouts. Eventually
she is sent to see a personality
psychiatrist Dr. Luther, and while
under hypnosis her "alter
personality", wild, fun-loving Eve
Black, discloses herself. With Eve
Black on the loose, Eve White's
husband leaves her and abandons
their daughter. Under continued
therapy, a third personality appears,
the relatively stable Jane.
Chris Costner Sizemore walking the red carpet at
the 51st Anniversary Encore Presentation of the
World Premiere of The Three Faces of Eve, 18
September 2008 at Augusta, Georgia.

16. People less easily
hypnotized use other
coping strategy and
DID does not
developed
Childhood Trauma
between ages 4 and 6
People skilled at self-
hypnosis use it to develop a
second personality, which
bears the brunt of the
trauma
When a new and different
trauma is experienced, a
third personality is created,
because the strategy of
creating another personality
successfully relieved the
earlier trauma
Model of Dissociative Identity Disorder [DID]

17. Dissociative Trance Disorder
• Trance: temporary marked alteration in the
state of consciousness or loss of
customary sense of personal identity
without replacement of alternate identity
• Possession trance: with replacement of
customary personal identity with a new
identity attributed to the influence of a
spirit, power, deity or other person.

18. DSM-IV Exclusion criteria: The trance or possession state causes clinically significant distress or
impairment in social, occupational, or other important area of functioning

19. DSM-IV Exclusion criteria: The trance or possession state is not accepted as a
normal part of a collective cultural or religious practice

20. http://worldrec.info/2008/09/10/smk-tanjung-lumpur-kuantan-pahang-malaysia-the-worlds-most-haunted-school

21. What did the affected students see?
(i) most claimed that they saw a being
with long hair
(ii) others claimed they were
possessed by an old woman. That was
apparently the reason why they acted
and sounded like one.
But some victim’s parents disagreed,
like Mariah Mat Zain who said: I’ve
seen my daughter [form 2 student]
turning her head more than 180
degrees. She could also overpower five
men when possessed. She had been
transferred to another school but she
still suffers from bouts of hysteria. Don’t
tell me she is faking it. She’s too young
to do it.
Hysteria at SMK Tanjung Lumpur, Kuantan, Pahang, Malaysia
The Exorcist [1973]

22. Dissociative Disorders NOS
• Individuals subjected to periods of
prolonged and intense coercive
persuasion
– e.g., brainwashing, or indoctrination while
captive
• Culture-bound syndrome
– e.g., amok, latah, and pibloqtoq
• Ganser syndrome:

23. Amok is often described as a culture-bound (or culture-
specific) syndrome, which is a psychological condition
whose manifestation is strongly shaped by cultural factors.
Amok is also sometimes considered one of the
subcategories of dissociative disorders (cross-cultural
variant)

24. Ganser Syndrome
• May be present in association with variety
of dissociative symptoms.
• Mainly in men, especially those
imprisoned in penal institutions.
• Characterized by pseudostupidity in the
person’s speech and behavior
– The person gives ridiculous answer to simple
question – replying “five” for instance when
asked “how much is two and two?”

25. Dissociative [conversion] disorders have an
unconscious motivation to resolve
intrapsychic conflict, and may show the
following
1. Primary gain [to resolve conflict or reduce
anxiety]
2. Secondary gain [e.g., the attention of others]
3. Symptom choice may be symbolic of the
conflict and reflect modeling of symptoms
either the individual or others have experienced
4. La belle indifference [calm acceptance of
symptoms]