Premnath R

Dissociative(Conversion) disorders

Jean Martin Charcot shows colleagues a female patient with hysteria at La Salpêtrière, a Paris hospital.

The syndrome currently known as

conversion disorder was originally

combined with the syndrome known as

somatization disorder and was referred to

as hysteria, conversion reaction, or

dissociative reaction.

Conversion disorder

Conversion disorder is characterised by the

presence of one or more symptoms suggesting

the presence of a neurological disorder that

cannot be explained by any known neurological

or medical disorder. Patients are unaware of the

psychological basis, and are thus not able to

control their symptoms. Conversion disorders are

formerly called as ‘hysteria’.

Definitions

Dissociative disorder

Dissociative Disorders is defined

as a state of disrupted

“consciousness, memory, identity, or

perception of the environment. It will

result in the significant impairment in

general and social functioning”.

Epidemiology

• Hysteria (comprising of conversion,

dissociation and somatization disorder)

constitutes about 6-15% of all outpatient

diagnoses and 14-20% of all neurotic

disorders.

• Females usually outnumber males, but in

children the percentage tends to be similar

in boys and girls.

Etiology of dissociative and conversion disorders

A) Psychological Theories

Psychodynamic Theory

• According to Freud, important defence

mechanisms involved in the formation of

conversion symptoms are repression, dissociation,

conversion, symbolization and identification.

• Repressed materials are sexual or aggressive

conflicts arising during oedipal phase of

development.

• Under the influence of a stressor, repression

fails partly or completely, leading to the

formation of a conversion or dissociation

symptom.

• Thus an unpleasant repressed material is

converted to somatic symptom leading to relief

of anxiety, in conversion. But, in dissociation, a

part of personality dissociated from the rest

and presented with features of dissociative

disorder.

B) Behavior theory

• According to this theory, the symptoms are

learnt from surrounding environment (e.g.

seeing a paralysed patient).

• These symptoms bring out psychological relief

by avoidance of stress and are thus

secondarily reinforced.

• Conversion disorder is more common in

people with histrionic personality traits.

C) Biological theory

(i)Neurophysiologic Theories.

• The observed sensory deficit seen in some

conversion disorder patients can be explained by

the elevated levels of corticofugal output, in turn,

inhibits the patient’s awareness of body sensation.

(ii)Genetic Theories

• There is an increased likelihood of conversion

disorder in the first-degree relatives of patients of

conversion disorder. Increased risk of conversion

disorder in monozygotic.

Common manifestations of Conversion disorder

1) Presence of symptoms or deficits affecting motor

or sensory function, suggesting a medical or

neurological disorder.

2) Sudden onset

3) Development of symptoms or deficits usually in

the presence of significant psychosocial stressors.

4) A clear temporal relationship between stressors

and development or exacerbation of symptoms.

5) Symptoms are not intentionally produced.

6) There is usually a secondary gain.

7) Detailed physical examination and investigation

do not reveal any medical disorder or substance

use disorder that can explain the symptoms

adequately.

8) The symptoms may have a symbolic relationship

with stressor or conflict.

Common manifestations of dissociative disorders

1) Disturbance in the normally integrated

functions of consciousness, identity, memory or

perception of the environment.

2) Onset is usually sudden and disturbance is

usually temporary. Recovery often is abrupt.

3) A precipitating stress is not uncommonly found

before the onset of disorder. There is a clear

temporal relationship between stressor and the

onset of the illness.

4) Secondary gain resulting from the

development of symptoms may be found.

5) Detailed physical investigation and

examination do not reveal any evidence of

the physical disorder that can explain the

symptoms present.

ICD-10 ClassificationF44 - Dissociative Disorders

F44.0 Dissociative amnesiaF44.1 Dissociative fugueF44.2 Dissociative stuporF44.3 Trance and possession disordersF44.4-F44.7 Dissociative disorders of movement

and sensationF44.4 Dissociative motor disordersF44.5 Dissociative convulsionsF44.6 Dissociative anaesthesia and sensory lossF44.80 Ganser's syndromeF44.81 Multiple personality disorder

F44.0 Dissociative amnesia• It involves amnesia for personal identity but intact

memory of general information. • This clinical picture is exactly the reverse of the one

seen in dementia, in which patients may remember their names but forget general information.

• Its key symptom is the inability to recall information, usually about stressful or traumatic events in people’s lives.

• Dissociative amnesia may take one of several forms:• Localized amnesia, (or circumscribed)• Generalized amnesia• Selective (systematized)• Continuous amnesia

• Localized amnesia, (or circumscribed) the

most common type, is the loss of memory for the

events of a short time (a few hours to a few days)

• Generalized amnesia is the loss of memory for a

whole lifetime of experience.

• Selective (systematized) amnesia is the failure

to recall some but not all events that occurred

during a short time.

• Continuous amnesia:-in which the individual

can not recall events subsequent to a specific

time up to and including the present.

F44.1 Dissociative fugue

• It is a sudden, unexpected travel away from

home or workplace, with the assumption of a

new identity and an inability to recall the past.

• The onset is sudden, often in the presence of

severe stress.

• Following recovery, there is no recollection of

events that took place during the fugue.

• The course is typically a few hours to days

and sometimes months.

F44.2 Dissociative stupor

• The individual's behaviour fulfils the

criteria for stupor.

• But examination and investigation reveal

no evidence of a physical cause.

F44.3 Trance and possession disorders

• This disorder is very common in India.

• It is characterized by temporary loss of both the

sense of personal identity and full awareness of

the person’s surroundings.

• When the condition is induced by religious rituals,

the person may feel taken over by a deity or spirit.

• The focus of attention is narrowed to few aspects

of immediate environment, and there is often

limited but repeated set of movements, postures

and utterances.

F44.4-F44.7 Dissociative disorders of

movement and sensation

In ICD-10, conversion disorder is included

under “Dissociative disorders of movement

and sensation”

– F44.4 Dissociative motor disorders

– F44.5 Dissociative convulsions

– F44.6 Dissociative anaesthesia and

sensory loss

F44.4 Dissociative motor disorders

• The commonest varieties of dissociative motor

disorder are loss of ability to move the whole or

a part of a limb or limbs.

• Paralysis may be a monoplegia, paraplegia, or

quadriplegia.

• Various forms and variable degrees of

incoordination (ataxia) may be evident,

particularly in the legs, resulting in bizarre gait

or inability to stand unaided (astasia abasia).

• These abnormal movements increase in

severity when attention is directed

towards them.

• There may be close resemblance to almost

any variety of ataxia, apraxia, akinesia,

aphonia, dysarthria, dyskinesia, or

paralysis.

F44.5 Dissociative convulsions

• Dissociative convulsions (pseudo seizures)

may mimic epileptic seizures very closely

in terms of movements, but tongue-biting,

serious bruising due to falling, and

incontinence of urine are rare in

dissociative convulsion, and loss of

consciousness is absent or replaced by a

state of stupor or trance.

F44.6 Dissociative anaesthesia and

sensory loss

• It is characterized by sensory disturbances like

hemianaesthesia, blindness, deafness and glove and

stocking anaesthesia (absence of sensations at wrists and

ankles).

• The disturbance is usually based on patient’s knowledge

of that particular illness whose symptoms are produced.

• A detailed examination does not reveal any abnormalities.

• Dissociative deafness and anosmia are far less common

than loss of sensation or vision.

Other dissociative [conversion] disorders

F44.80 Ganser's syndrome

F44.81 Multiple personality disorder

F44.80 Ganser's syndrome

• The complex disorder described by Ganser.

• This condition occurs in prisoners awaiting trial. 

• It is characterized by “vorbeireden” or

"approximate answers", (for example, when asked

to multiply 4 times 5, the patient answers 21)

usually accompanied by several other dissociative

symptoms, often in circumstances that suggest a

psychogenic etiology.

F44.81 Multiple personality 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, behaviour, and preferences;

these may be in marked contrast to the

single premorbid personality.

• 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 always

unaware of each other's existence.

• Change from one personality to another in

the first instance is usually sudden and

closely associated with traumatic events.

Management

The treatment usually consists of two

parts:

• Early treatment directed towards symptom

removal.

• Long- term treatment directed towards

resolution of conflicts and prevention of further

episodes.

(i) Psychotherapy

• Establishment of rapport and therapeutic

alliance is often useful to communicate to the

patient that he is responding to the stresses in

life.

• The therapist tries to help the patient be aware

of his tendency to use dissociation and amnesia

to deal with painful conflicts, and understand

and accept his individual conflicts so they can

be integrated in to the primary personality.

• Regularity of follow-up visits after

discharge is important so that the patient

does not need to 'produce’ a symptom to

visit the therapist.

• Problem-solving techniques and stress

management techniques are important

adjuncts of long-term successful therapy.

(ii) Behavior Therapy:

• When there is a sudden, acute symptom, its

prompt removal may prevent habituation and

future disability. This may be achieved by one

of the following methods:

• a) Aversion therapy for unwanted behaviour

has been employed in resistant cases, using

liquor ammonia, aversive faradic stimulation,

pressures just above eyeballs, tragus of ear or

over sternum, and closing the nose and mouth.

• b) Morrison’s behaviour modification

technique involves selective attention (or

inattention) and verbal rewards.

• c) The other behavioural techniques employed

in the treatment include modelling, shaping,

relaxation methods, systematic desensitization.

(iii)Abreaction

Abreaction is bringing to conscious

awareness, thoughts, affects and memories for

the first time, with or without the use of drugs.

This may be achieved by:

• Hypnosis

• Free association

• Drugs {thiopentone (Pentothal), amobarbital

(Amytal), ketamine, diazepam, methylphenidate,

or methamphetamine (methedrine)}

• The aim of abreaction with IV amobarbital

or thiopentone is, both, to make the conflicts

conscious and to make the patient more

suggestible to therapist’s advice. It is best to

begin with neutral topics and to approach

affect laden or traumatic material gradually.

(iv) Drug Therapy

• Very limited role .

• IV thiopentone, amytal or diazepam used

for abreaction and suggestion.

• Patients with disabling symptoms need

short-term benzodiazepines.

(v) Hospitalization

• If the symptoms are disabling or alarming to the

family.

• Helps to remove the patient from the stressful

situation.

• Demonstrate to the patient and significant

others that the matter is important but will not

elicit the kind of attention patient wants, and

lead to the resolution of the trauma.

• Secondary gains must be minimized.

(vi) Family and Marital Therapy

• Direct communication with the family

members will also reduce the opportunities

for manipulation and misunderstanding.

(vii) Supportive psychotherapy

• It is needed especially when the conflicts

have become conscious and have to be faced

in routine life.

(viii) Group Therapy

• Participation in a group setting may diminish

the patient’s sense of loneliness, make

available a secure place to discuss traumatic

matter that patients without dissociative

disorder may not be able to tolerate, to study

interpersonal relationships, to develop more

functional interactions, and learn more about

coping mechanisms.

NURSING MANAGEMENTNursing diagnosis 1Risk for violence self-directed or other

directed violence related to low self esteemGoal: Client demonstrates non violent

behaviourInterventions• Intervene immediately when violence to

client or others is imminent.• Examine the client behaviour closely for

abrupt changes that may signal a risk for suicide.

• Provide a safe environment for patients.

• Provide a consistent, structured environment.

Let the client know what is expected from him.

• Assist the client to identify alternatives to

aggression or violence.

• Engage the client in appropriate insight

oriented therapy.

• Praise the client for attempts to control anger

and rage and for participation in ongoing

therapeutic regimen.

• Encourage supervised physical activity.

Nursing diagnosis 2

Ineffective coping related to overwhelming

stressors that exceeds the ability to cope

repressed anxiety and inadequate coping

methods as evidenced by client demonstrates

inappropriate use of defence mechanisms like

amnesia, presence of alternate personalities etc.

Goal: Client identifies ineffective coping

behaviours and their negative effects on life

functions, relationships and activities.

Interventions

• Protect the patient from harm or injury during

dissociative episodes (amnesia).

• Demonstrate to the client the importance of

discussing stress situations and exploring associated

feeling.

• Structure the environment to reduce stimulation,

such as loud noises, bright lights, or extraneous

movement.

• Praise the client for using effective coping strategies.

• Engage the client in appropriate therapies.

Nursing diagnosis 3

Impaired social interaction related to depletion of effective

coping mechanisms as evidenced by unsatisfactory or

inadequate interpersonal relationships.

Goal: Client maintains active relationship with the

immediate surroundings.

Interventions:

• Approach the client in a calm, direct, non-authoritarian

manner, using a soft tone of voice.

• Assist the client to gain control of overwhelming feelings

through verbal interactions.

• Teach the client social skills, and encourage

him or her to practice these skills with staff

members and other client.

• Give the client feedback regarding social

interaction.

• Encourage the client to pursue personal

interests, hobbies, and recreational activities.

• Encourage the client to identify supportive

people outside the hospital and to develop these

relationships.

Thank you