Dissociative (Conversion) Disorders

Published October 18, 2010

Dissociative (Conversion) Disorders

v Introduction and Definitions:

These terms replaced the old concept of hysteria (moving womb). However the term is still used until today even by clinician. It is best avoided as it creates clinical confusion and miscommunication.

The concept is that symptoms of physical illness or certain kind of mental illness have occurred in the absence of physical pathology with which they are normally associated and that the symptoms have been produced unconsciously.

The ICD 10 use the term interchangeably while the DSM-IV uses conversion for physical symptoms and dissociative for mental symptoms.

In the next sections the terms will be used interchangeably (ICD 10) for simplicity

Dissociative disorders can occur as primary disorder or as a feature of another psychiatric (e.g. depression) or organic disorder (temporal lobe epilepsy).

v Underlying “Mechanism of Action”:

The psychoanalytical explanation still offers the most plausible explanation for the occurrence of the symptoms of the disorder.

Although the symptoms are not produced deliberately, they present the patients ideas about the illness (i.e. from a personal experience or relative experience)

The symptoms usually confer some advantage to the patient:

Primary gain: exclusion from consciousness of anxiety due to psychological conflict. Repression of the i.d. Secondary gain: visible gain such as paralysis in the hand of a person taking care of an elderly. Secondary gain is extremely important to establish diagnoses and it should be reconsidered if it is absent. v Epidemiology:

Prevalence 3-6/1000 .F>M. very rare after 40 (suspect organicity)

v Aetiology:

•1. Genetic: not very strong evidence although relatives have slightly higher rate. Twin studies do not support a strong genetic etiology. However somatization appears to be higher in relatives of patient with dissociation.

•2. Organic: Some organic diseases can present with dissociation, especially if the CNS is involved (left side more than right). Recently huge interest and studies focus on the “organic” factors and possible neurological mechanism.

•3. Psychological: Generally accepted that this is the immediate cause. The essential feature seems to be the capacity to dissociate i.e disconnects one aspect of psychological function from the rest when the person is subjected to severely stressful events.

•4. Cultural: there has been decrease over the last decades especially in developed countries. Support for the role of social and cultural factors comes from studies showing that dissociative disorders are common among people from rural areas and lower socioeconomic class.

•5. Personality: more common in immature personalities and in personality disorders in general.

v Examples of Dissociative (conversion) Disorders:

-Dissociative Amnesia:

Sudden onset. A Person unable to recall long periods of life and may deny any knowledge of their previous life or personal identity. Some have concurrent organic disease (e.g. Epilepsy, MS or head injury), these patients with organic disorders may have similar symptoms and may be as suggestible as those without it.

-Dissociative Fugue:

Often occurs after severe stress. There is a loss of memory and wandering away from usual surrounding. When found the individual usually deny all memory of their whereabouts and may deny knowledge of personal identity. Fugue also occurs in epilepsy, severe depression and alcoholism. It may be associated with suicide attempts. Many give a history of severely disturbed relationship with their parents in childhood and others are habitual liars.

-Dissociative Stupor:

The patient is motionless and mute, not responding to stimulation, but aware of their surroundings. It is rare, but excludes schizophrenia, depression, mania and organic brain disorder.

-Ganser’s Syndrome:

Rare, commoner in prisoner, exclude psychosis (functional or organic) consist of four features:

1. Giving ‘approximate answers’ to questions of intellectual function (e.g. 2+2= 5) 2. Psychogenic physical symptoms 3. Hallucinations (? Pseudo hallucinations) usually visual and elaborate. 4. Apparent clouding of consciousness.

-Dissociative Identity Disorder (Multiple Personality Disorder):

Sudden alteration between two patterns of behavior each of which is forgotten by the patient

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