MANAGEMENT OF DISSOCIATIVE DISORDERS

FAREED MINHASProfessor of Psychiatry

HEAD, Institute of PsychiatryRawalpindi Medical College

Rawalpindi

NEUROTIC, STRESS RELATEDAND

SOMATOFORM DISORDERS

FAREED MINHASProfessor of Psychiatry

HEAD, Institute of PsychiatryRawalpindi Medical College

Rawalpindi

INTRODUCTION Disorders here grouped due to association with

- concept of neurosis- psychological causation

NEUROSIS : when the person experiencing the symptoms of mental disorder retains insight into his condition ( in touch with reality)

This block in ICD-10 includes : anxiety disorders, obsessive-compulsive disorders, dissociative disorders, somatoform disorders and reactions to severe stress/ adjustment disorders

PERCENTAGE OF MAJOR DIAGNOSTIC CATEGORIES DURING FOUR YEARS IN IOPJournal of CPSP (2001)

Fig.3 Percentage of major diagnostic categories.

overall%

Males

Females

overall% 8.40% 37% 11.40% 4.80% 10.60% 1.50% 1.43% 4.80%

Males 5.70% 18% 4.15% 2.90% 10.60% 0.92% 0.95% 0.60%

Females 2.70% 19% 7.20% 1.90% 0% 0.66% 1.90% 4.20%

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ANXIETY DISORDERS

• Abnormal states in which the most striking features are mental and physical symptoms of anxiety not caused by organic brain disease or other psychiatric disorder

Generalized Anxiety

Disorder

Unvarying and persistent

anxiety

Phobic Anxiety Disorder

Intermittent; arising in special

circumstances

Panic Disorder

Intermittent but unrelated to particular

circumstances

Generalized Anxiety Disorders

The symptoms of generalized anxiety disorder include:

Psychological- Fearful anticipation; irritability; sensitivity to noise; restlessness, poor concentration, worrying thoughts

Physical- Gastrointestinal: Dry mouth-difficulty in swallowing-epigastric

discomfort -excessive wind-loose motions

Respiratory: Constriction in chest-difficulty inhaling-overbreathing

Cardiovascular: Palpitations-discomfort in chest-awareness of missed beats

Generalized Anxiety Disorders (contd.)

Genitourinary: Frequent/Urgent micturition-Failure of erection-menstrual discomfort- amenorrhoea

Neuromuscular: Tremor-prickling sensations- tinnitus-dizziness-

headache-aching muscles

Sleep disturbances- Insomnia; night terrors

Other symptoms- Depression; obsessions; depersonalization

Differential Diagnosis : DEPRESSIVE DISORDER SCHIZOPHRENIA PRESENILE/SENILE

DEMENTIA PHYSICAL ILLNESS (Thyrotoxicosis -Pheochromocytoma-Hypoglycemia)

Aetiology of GAD

Stressful events

Genetic causes

PersonalityEnvironmenta

l influences

Treatment

Counseling

Cognitive Behavior Treatments (anxiety management training)

Drug therapy (benzodiazepines; tricyclic antidepressants and beta-blockers)

OBSESSIVE-COMPULSIVE DISORDERS(Contd.)

Differential Diagnosis: GENERALIZED ANXIETY PANIC DISORDER PHOBIC DISORDER DEPRESSIVE DISORDERS SCHIZOPHRENIA ORGANIC CEREBRAL

DISORDER Aetiology : Genetics, evidence of brain disorder,

abnormal serotinin levels and environment

Treatment- Counseling; drugs(anxiolytics short-term; tricyclic antidepressant long-term or an SSRI); behavior therapy; psychotherapy and psychosurgery

Phobic Anxiety Disorders Same core symptoms as in GAD but they occur

in special circumstances. The patient is free from anxiety rest of the time. 2 features characteristic are: - person avoids these situations - anticipatory anxiety

Phobic syndromes fall into 3 categories mostly:- Simple phobia- Social phobia- Agoraphobia

Mostly the treatment here is psychological (cognitive behavior therapy) however drugs (antidepressants and benzodiazepines) are also added

Phobic Anxiety Disorders(contd.)

Simple Phobia – the person is inappropriately anxious in presence of one or more particular objects or situation. Eg. Arachnophobia (spider phobia)

acrophobia (phobia of height) phobia of flying phobia of illness

Social Phobia – inappropriate anxiety is experienced in situations in which the person is observed and could be criticized. Eg. Phobias of excretion

Phobias of vomiting Agoraphobia – patients are anxious when they are

away from home, in crowds and situations they can’t leave easily from.

Panic Disorder Panic disorder is episodic paroxysmal anxiety

characterised by recurrent attacks of severe anxiety which are not related to any situation and unpredictable

Symptoms of a ‘panic attack’ :- Shortness of breath and smothering

sensations - Choking- Palpitations and accelerated

heart rate - Chest discomfort or pain- Sweating- Dizziness,

unsteady feelings or faintness - Nausea or abdominal distress

Panic Disorder(contd.)

- Depersonalization or derealization - Numbness or tingling sensations - Flushes or chills - Trembling or shaking - Fear of dying - Fears of going crazy or doing something uncontrolled

The aetiology is based on 3 hypothesis:- Biochemical (endogenous anxiety) - -

Hyperventilation - Cognitive hypothesis

Treatment- Benzodiazepines and antidepressants

(TCAs/SSRIs)- Rebreathing into a shopping bag

OBSESSIVE-COMPULSIVE DISORDERS

Characterized by obsessional thinking, compulsive behavior, varying degrees of anxiety, depression and depersonalization

Main features maybe:- Obsessional thoughts/images- Obsessional ruminations/doubts

- Obsessional impulses- Obsessional rituals

- Obsessional phobias- Obsessional

slowness

DISSOCIATIVE DISORDERS Dissociative [conversion] disorders involve partial or

complete loss of the normal integration between the memories of the past, awareness of identity and immediate sensations, and control of bodily movements

Level of consciousness about the episode may vary and is difficult to assess

Several forms of dissociation are seen: Dissociative amnesia: sudden loss of memory

[usually short-term] which is not due to concurrent organic disease such as epilepsy, multiple schlerosis

DISSOCIATIVE DISORDERS(Contd.)

Dissociative pseudodementia: disorder with extensive abnormalities of memory and behavior that suggest generalized intellectual impairment. Simple tests are answered wrong though in a way strongly suggesting that the correct answer is in the patient’s mind

Dissociative fugue: is a state of amnesia alongwith a purposeful journey to a place out of daily range during which self-care and basic interaction is maintained

Dissociative stupor: the patient is motionless, mute and not responsive to stimulation in the absence of any physical or psychiatric finding and presence of a recent stress factor

DISSOCIATIVE DISORDERS(Contd.)

Trance and possession disorders : there is temporary loss of both personal identity and full awareness of surroundings. Focus of attention is narrowed to few aspects of environment. The person repeats movements, adopts postures or repeats utterances

Dissociative identity disorder : multiple personality disorder where the person switches between two personalities without being aware of it

Ganser’s Syndrome : presence of ‘approximate answers’ to questions for intellectual functioning; psychogenic physical symptoms; hallucinations and clouding of consciousness

DISSOCIATIVE DISORDERS(Contd.)

Dissociative disorders of movement and sensation : there is a degree of physical disability and loss of usually cutaneous sensations against all physical evidence

Dissociative motor disorders : loss of ability to move part or whole of the limb or exaggerated shaking/trembling of one or more extremities or whole body

Dissociative convulsions : pseudoseizures. They resemble epileptic fits but tongue-bite, fall and urinary incontinence are rare[almost absent]

Dissociative anaesthesia or sensory loss

Follow up studiesSlator(1965)National Hospital for Nervous

disease. 85 patients followed up for 9 years

60 % Organic disease 17 % had serious psychiatric disease 13 % had lasting personality disorder 10% had acute psychogenic reaction The diagnosis of hysteria as a

dangerous myth. “Not only a delusion but also a snare”

The survival of hysteria, A. Lewis(1975) 98 patients suffering from Hysteria, Maudsley hospital, 7-12 years

26 - diagnosis was retained 54 - well and working 11 - other psychiatric disorders 7 - died, one by suicide “a though old word like hysteria,

dies very hard. It tends to outlive its obituarists”

Faith Healers diagnosis

Saya Jinn possession Churail possession Tawiz Dar

Spirit infestation Evil eye Amal Jhalla / Jhally Jadoo

Etiology

Psychoanalytic terms- primarily a defense mechanism, withdrawal from a painful stimuli

Premorbid personality and Mood disorders

Stressors and Psychosocial factors- marital, financial, occupational, war-related stressors

DISSOCIATIVE DISORDERS(Contd.)

The treatment is focused on elimination of factors reinforcing the symptoms and encouragement of normal behavior.

Other ways of treatment resorted to:- abreaction- dynamic psychotherapy

DEPERSONALIZATION DISORDER is a separate class characterised by an unpleasant state of perception in which external objects or parts of body are experienced as unreal/remote/automized.

THANK YOU

References: - OXFORD TEXTBOOK OF PSYCHIATRY(Third

Edition) - ICD-10 (Clinical and

Diagnostic Guidelines)