type of presentation of dissociative disorder and ... · dissociative disorder according to gender...

Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 113-116 113

INTRODUCTION

The classification of dissociative disorder hasconsiderably evolved in the recent past. There ismarked discrepancy in the psychiatric literatureregarding frequency of dissociative disorder inpsychiatric patients and even in general population.Category and subcategories given in differentclassification systems do not fulfill requirements ofdifferent parts of the world.1 Thus significant number ofpatients does not fit into the diagnostic criteria given byInternational Classification of Disease 10 DiagnosticCriteria for Research and Statistical Manual IV.2 As faras presentation of dissociative disorders is concerned,almost any physical symptom can be produced but mostcommon manifestations are those that suggest aneurological disease, for example: paraparesis,pseudoseizures and aphonia.3 The patients withconversion disorder usually report in emergencydepartment with multiple neurological symptomsincluding weakness, seizures like activity and loss of

consciousness.4 In a hospital-based study, thecommonest presenting symptom was found to be'pseudoseizures', which presented in 45.71% femalesubjects as compared with 26.65% in male subjects.5Another study revealed that 31.3% cases presentedwith unresponsiveness - a symptom which does not fitany diagnostic criteria, jerky movements, aphonia andsensory loss, and 18.1% others.6 Another studyreported pseudoseizures, paralysis, tremors, aphonia,gait disorders, mutism, blindness and anesthesia indecreasing frequency.7

In an overview of diagnosis and treatment ofdissociative disorder by Johnson, the commonestsymptom profile of adults who had been abused aschildren included post-traumatic stress disorder anddissociative disorder co-morbid with depression, anxietyand addiction.8 Patients with pseudoseizures,interviewed to determine the course of illness andcurrent diagnosis, had affective disorders, dissociativedisorders and post-traumatic stress disorders.9 In astudy of conversion disorder in children and adolescent,co-morbid depression was found in 15.7% cases andanxiety in 37.2% cases.10 Non-epileptic seizure caseswere found to have depressive symptoms in 51.8% ofpatients.11

The objective of this study was to determine thedistribution of various types of dissociative disorders,

ABSTRACTObjective: To determine the frequency distribution of various types of dissociative disorders, along with existing co-morbiddepression and its level of severity in patients with dissociative disorder.Study Design: Observational, cross-sectional study.Place and Duration of Study: The Institute of Psychiatry, Rawalpindi General Hospital from October 2004 to March 2005.Methodology: Fifty consecutive patients were included in the study through non-probable purposive sampling technique.Encounter form included socio-demographic profile and brief psychiatric history. ICD 10 diagnostic criteria for researchwere administered for determining the presentation of dissociative disorder. Present state examination was applied tomake diagnosis of depressive disorder in the studied patients. Descriptive statistics for frequency analysis of socio-demographic variables, type of presentation of dissociative disorder and the frequency of depressive disorder in patientsof dissociative disorder. Results: The mean age was 23.6±8.67 years with female preponderance (n=40, 80% patients). Most of them were single,unemployed and belonged to urban population. Main stress was primary support group issue. Mixed category ofdissociative disorder was highest (n=18, 38%) followed by unspecified and motor symptoms (n=13, 26%) in each group.Depression was present in 42 (84%) patients. Moderate depression was most frequent (n=19, 38%). Conclusion: Mixed dissociative symptoms were found in 38%, while 26% had motor and unspecified category ofdissociative symptoms respectively. Depressive disorder was present in 42 (84%) cases of dissociative disorder with 38%having moderate depression.

Key words: Dissociation. Depression. Conversion.

Department of Psychiatry and Behavioural Sciences, WahMedical College, Wah Cantt.

Correspondence: Dr. Tabassum Alvi, Assistant Professor,Psychiatry and Behavioural Sciences, Wah Medical College,Wah Cantt.E-mail: tabassumalvi@yahoo.com

Received March 6, 2008; accepted October 31, 2008.

Type of Presentation of Dissociative Disorder and Frequency of Co-morbid Depressive Disorder

Tabassum Alvi and Fareed Aslam Minhas

ORIGINAL ARTICLE

the frequency of co-morbid depression and its level ofseverity in patients with dissociative disorder.

METHODOLOGY

The study was conducted at the Institute of Psychiatry,Rawalpindi General Hospital, which commenced inOctober, 2004 and concluded in March, 2005. The studypopulation comprised of diagnosed cases ofdissociative disorders confirmed through InternationalClassification of Disease 10 Diagnostic Criteria forResearch at the in-patient and outpatient departmentsof the institute. Every consecutive patient of dissociativedisorder presenting at the Institute of Psychiatry duringthe data collection period till the attainment of samplesize of 50 were included.

The inclusion criteria was diagnosed patient for the firsttime to be a case of dissociative disorder based on thehistory, signs and symptoms and InternationalClassification of Disease 10 Diagnostic Criteria forResearch as evaluated by psychiatrist. All patients withany other co-morbid psychiatric or medical disorder(apart from depression) were excluded.

Informed consent was obtained from patients duringwhich procedure and purpose of the study wasexplained to the patients. The data collection techniquecomprised of observation (like record checking, physicalexamination and mental state examination) andinterviewing to record history, to collect informationregarding study variables (like types of dissociativedisorder, absence or presence of depression throughconfirmed diagnosis by using present stateexamination) and also to determine existence of anystress factors.

The data collecting tools used were checklists forpsychiatric examination and questionnaire. Theoutcome variables of interest were types of dissociativedisorder in the study participants based on InternationalClassification of Disease 10 Diagnostic Criteria forResearch, absence or presence of co-morbiddepression, level of severity of depression based onpresent state examination, absence or presence ofstress factor by using stressors categorized byDiagnostic and Statistical Manual IV.

For data entry and analysis, the SPSS version 10 wasused. Simple frequencies and percentages werecalculated for categorical variables like types ofpresentation of dissociative disorder, absence orpresence of depression and categories of severity ofdepression. For continuous variables, descriptivestatistics including mean and standard deviation werecalculated. Graphs were plotted, using Microsoft ExcelSoftware.

RESULTS

A total of 50 patients with confirmed diagnosis of

dissociative disorder were included in this study. Theage ranged from 11 to 45 years with a mean of23.6±8.67 years. Amongst 50 patients, 40 (80%) werefemales and 10 (20%) were males. The socio-demographic profile showed that 31 (62%) patientswere single. Twelve (24%) patients were illiterate, 12(24%) patients received primary education, 7 (14%)were matriculate, 3 (6%) patients had passedintermediate, 4 (8%) were graduates and 3 (6%) hadreceived higher education. Forty-two (84%) wereunemployed. Thirty-two (64%) were urbanites and 18(36%) belonged to rural areas. All the patients belongedto either the lower or middle socioeconomic group (23vs. 27; 46 vs. 54%). Past history of psychiatric illnesswas found in 11 (22%) and family history of psychiatricillness was present in 15 (30%) of cases. Stressors werepresent in 97% patients, out of whom, 32 (64%) hadprimary support group issue, educational stress in 10(20%), 5 (10%) had social problems, 2 (4%) hadeconomic issues and 1 (2%) had health problems.

The subjects presented with different symptoms, whichwere categorized according to International Classi-fication of Disease 10 Diagnostic Criteria for Research.These included mixed dissociative symptoms in 18(36%), followed by motor in 13 (26%) and unspecified

type in 13 (26%) respectively. Details are given inFigure 1.

When assessed for absence or presence of co-morbid

114 Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (2): 113-116

Tabassum Alvi and Fareed Aslam Minhasn

Figure 1: Bar chart showing distribution of various types of presentation ofdissociative disorder according to gender in the study participents.

Table I: The distribution of co-morbid depressive disorder in patientsof dissociative disorder according to gender.

Level of depression Frequency (percentage)Males Females Total

No depression 1 7 8 (16%)Mild depression 2 10 12 (24%)Moderate depression 2 17 19 (38%)Severe depression 5 6 11 (22%)Total 10 40 50 (100%)

depressive disorder, it was found in 42 (84%) ofpatients. The severity and distribution according togender is shown in Table I.

DISCUSSION

The present study was carried out to determine thesymptomatology of dissociative disorder and its co-existence with depressive disorder. The mean age of thesample was 23.6±8.67 years, which was similar to theprevious study age of 19-21 years and 24 yearsrespectively.2,15 There is general consensus in severalresearches about female preponderance of patients withconversion disorder, which was congruous with findingsin this study.4 Majority of participants belonged to urbanareas and were literate (70%), which was contrary toprevious findings of conversion disorder being commonamong rural population and having limited education.7

The reason might be the fact that the study setting wassituated in an urban area with more educationalfacilities. Most of previous studies showed predomi-nance of dissociative disorders among marriedsubjects,2 however, majority of participants in this studywere single. This difference may be due to the fact ofhaving majority of urban population where trends arechanging regarding age of marriages nowadays.Results suggest that most of the participants belongedto lower 23 (46%) and middle 27 (54%) socioeconomicclasses, but none of them belonged to highersocioeconomic class, which is similar to a Libyanstudy,12 but contrary to the past work. Past and familyhistory of psychiatric illnesses was present in 11 (22%)and 15 (30%) of patients respectively, which was closeto the findings in a previous study done by Yousafzai.7

According to Kendal and Zealley, conversion hysteria ischaracterized by sudden onset of symptoms in clearrelation to stress.3 In this study, 97% of patients showedstressors. Present research showed mixed dissociativedisorder symptoms as the single largest category ofpresentation. It presented in the form of convulsions withmotor symptoms, unresponsiveness and in few cases ofamnesia along with motor symptoms or convulsions. Itreflects the local and cultural ideas about acceptableand credible ways to express mental distress. Mixedcategory is not found on large scale in other researchwork, perhaps due to use of different classificationsystem.6,7 Dissociative motor disorder found in 26% ofcases presented with difficulty in walking. These figuresare comparable with 19%,13 22%5 and 39%7 found inprevious studies. Equally frequent was the unspecifiedtype of presentation. In this category, most of thepatients were presented with irrelevant talk with orwithout amnesia, making inappropriate facialexpressions and regressed behaviour. This category ofsymptoms has not been mentioned by other studies.6,7

Patients presented with dissociative convulsions in only

4 (8%) cases, whereas in the study of Rehman, it wasthe largest category present in 35% subjects and inother studies, it was present in 35%, 34% and 21% ofpatients.7,5,12 This difference is also attributable to thedifference in the study population.

The frequency of depressive disorder in patients withdissociative disorders was found to be 42 (84%) withmajority having moderate depression. This studyrevealed that dissociation disorder presents differently inour culture, therefore, classification system ofDiagnostic and Statistical Manual IV and InternationalClassification of Disease 10 Diagnostic Criteria forResearch need to be revised for our part of the world.This is the second study in civil setup; other studiesshould be planned with larger sample size so thatresults could be generalized.

CONCLUSION

The type of dissociative symptoms prevalent in this partof the country were found to be different from otherinternational as well as national studies. Mixeddissociative disorder was the commonest presentation,followed by motor and unspecified symptomsrespectively, convulsions, possession, anesthesia andsensory loss. Depression was found in 40 (80%) ofcases in different intensities, majority having moderatedepression.

Acknowledgement: I am obliged to Dr. Asad Nizamiand Mrs. Fatima Asad for initial spadework and helpingme to form skeleton.

My special tributes to Rasheeda Niazi and Dr. FaizaAslam who helped me in doing statistical analysis.

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