Dissociative and Conversion disorders

1. Premnath R
Dissociative(Conversio
n) disorders

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

3. 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.

4. 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

5. 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”.

6. 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.

7. 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.

8. • 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. ICD-10 Classification
F44 - Dissociative Disorders
F44.0 Dissociative amnesia
F44.1 Dissociative fugue
F44.2 Dissociative stupor
F44.3 Trance and possession disorders
F44.4-F44.7 Dissociative disorders of movement and
sensation
F44.4 Dissociative motor disorders
F44.5 Dissociative convulsions
F44.6 Dissociative anaesthesia and sensory loss
F44.80 Ganser's syndrome
F44.81 Multiple personality disorder

16. 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

17. • 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.

18. 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.

19. F44.2 Dissociative stupor
• The individual's behaviour fulfils the criteria for
stupor.
• But examination and investigation reveal no
evidence of a physical cause.

20. 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.

21. 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

22. 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).

23. • 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.

24. 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.

26. 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.

27. Other dissociative [conversion]
disorders
F44.80 Ganser's syndrome
F44.81 Multiple personality disorder

28. 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.

29. 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.

30. • 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.

31. 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.

32. (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.

33. • 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.

34. (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.

35. • 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.

36. (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)}

37. • 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.

38. (iv) Drug Therapy
• Very limited role .
• IV thiopentone, amytal or diazepam used for
abreaction and suggestion.
• Patients with disabling symptoms need short-
term benzodiazepines.

39. (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.

40. (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.

41. (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.

42. NURSING MANAGEMENT
Nursing diagnosis 1
Risk for violence self-directed or other directed
violence related to low self esteem
Goal: Client demonstrates non violent behaviour
Interventions
• 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.

43. • 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.

44. 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.

45. 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.

46. 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.

47. • 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.

48. Thank you