Dissociative disorder

This slide contains information regarding Dissociative Disorder. This can be helpful for proficiency level and bachelor level nursing students. Your feedback is highly appreciated.

1. Dissociative (Conversion) Disorders Nabina Paneru

2. Introduction Dissociative or conversion disorders are a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements.

3. Classification 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 anesthesia and sensory loss F44.7 Mixed dissociative [conversion] disorders

4. Contd. F44.8 Other dissociative [conversion] disorders .80 Ganser's syndrome .81 Multiple personality disorder .82 Transient dissociative [conversion] disorders occurring in childhood and adolescence .88 Other specified dissociative [conversion] disorders F44.9 Dissociative [conversion] disorder, unspecified

5. Dissociative amnesia Most common type Sudden inability to recall important personal information, particularly concerning stressful or traumatic experiences

6. Types of dissociative amnesia 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: Amnesia for certain categories of memory, such as all memories relating to one’s family or a particular person.

7. Dissociative Fugue In this, the person suddenly and without any warning cant remember who they are and has no memory of their past. They don’t realize they are experiencing memory loss and may invent a new identity. Typically, the person travels from home – sometimes over thousands of kilometers- while in fugue, which may last between hours and months. When the person comes out of their dissociative fugue, they are usually confused with no recollection of the ‘new life’. They have made for themselves.

8. Dissociative stupor Profound absence of voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch, but examination and investigation reveal no evidence of a physical cause. In addition there is positive evidence of psychogenic causation in the form of recent stressful events or problems.

9. Trance and possession disorders Temporary loss of the sense of personal identity and full awareness of the surroundings. During the episodes the persons personality may be controlled by “Spirit”

10. Dissociative motor disorders It is the commonest varieties with either paralysis or abnormal movements. Paralysis can be mono, para or quadriplegia. Abnormal movements can range from tremors, choreiform movements and gait disturbances. These either occur or increase when attention is directed towards them.

11. Dissociative convulsions Earlier it is known as hysterical fits. It is characterized by the presence of convulsive movements and partial loss of consciousness.

12. Difference between epileptic and dissociative convulsions Clinical features Epileptic S Dissociative convulsion Attack pattern Stereotyped Absence of any established pattern Place of occurrence Anywhere Usually indoors or at safe place Warning Aura is present Variable Time of the day Anytime, can occur during sleep Never occur in sleep Tongue bite Usually present Absent Incontinence of urine & feces Can occur Very rare Injury Can occur Very rare

13. Contd. Clinical features Epileptic S Dissociative convulsions Speech No verbalization during seizure Verbalization may occur Duration Usually about 30 – 70 s (short) 20 – 800 s (Prolonged) Head turning Unilateral Side to side turning Amnesia Complete Partial Post – ictal confusion Present Absent EEG Abnormal Normal Serum Prolactin Increased in post – ictal period Usually normal

14. Dissociative anesthesia and sensory loss Characterized by sensory disturbances like glove & stocking anesthesia, blindness or contracted visual fields and deafness.

15. Other dissociative disorders Ganser’s syndrome: Commonly found in prison inmates It is characterized by wrong answers to questions or doing things incorrectly Other dissociative symptoms such as fugue, amnesia often with visual pseudo hallucinations and a decreased state of consciousness.

16. Contd. Multiple personality: The person is dominated by two or more personalities of one is being manifest at a time. One personality is not aware about the existence of others.

17. Contd. Mass hysteria It is a phenomenon in which a group of people simultaneously exhibit similar hysterical symptoms. Technically mass hysteria involves physical effects such as headache, nausea, dizziness, or trance like state or seizure like movements. However this term is also commonly used to refer to any mass delusion in which group of people become governed by irrational beliefs or moral panic. Mass hysteria is most common in enclosed areas such as schools, factories, and hospitals are typical settings.

18. Epidemiology Lifetime risk of 33% for either transient or longer – term disorder Range in general population of 11-33/100,000 25 – 30% of admissions to hospitals Onset at any age but most common in late childhood to early adulthood Man: women = 1:2 to 1:10

19. Etiology Biologic theory Genetic theory: There is increased likelihood of conversion disorder in the first – degree relatives of patients of conversion disorder. Increase risk in monozygotic twins. Physical illness, brain damage etc.

20. Contd. 2. Psychodynamic theory: Primary defense mechanism (Repression): Repression of unconscious intrapsychic conflicts (instinctual impulse, e.g. aggression/sexuality, and prohibitions of expression) the primary defense mechanism fails use of secondary mechanism like dissociation & conversion

21. Contd. 3. Behavioral theory: Symptoms are learned response in the face of stress Classically conditioned learned behavior

22. Clinical features Anesthesia and paresthesia is common, especially in extremities (although all sensory modalities can be involved) Possible involvement of organs of special sense (deafness, blindness, tunnel vision) Abnormal movements (gait disturbance, weakness/paralysis) Movements generally worsen with calling of attention

23. Contd. Possible gross rhythmical tremors, chorea, tics and jerks Paralysis/paresis involving one, two or all four limbs Normal electromyography Pseudo seizures

24. Diagnostic criteria The clinical features as specified for the individual disorders No evidence of a physical disorder that might explain the symptoms Evidence for psychological causation, in the form of clear association in time with stressful events. And problems or disturbed relationships (even if denied by the individual).

25. Investigations Laboratory studies i.e. electrolyte disturbances, hypo/hyper glycemia , renal function test, system infection, toxins, other drugs Imaging studied i.e CXR, CT scan or MRI Electroencephalography Lumbar puncture * Note: Avoid unnecessary, painful or invasive test if possible as they can results in reinforcement and fixation of symptoms

26. Treatment Behavioral therapy: Patient should be treated as normal and not encouraged to stay in sick – role. Psychotherapy with Abreaction: Abreaction is bringing to the conscious awareness, thoughts, affects and memories for the first time. This may be achieved by : Hypnosis or free association

27. Contd. 2. Other therapy: Cognitive behavioral therapy, family therapy 3. Drug therapy: Drugs have very limited role. A few patients have anxiety and may need short term treatment with benzodiazepines, antipsychotic for hysterical psychosis.

28. Nursing management From book