UNIT-12

DISSOCIATIVE CONVERSION DISORDERS

INTRODUCTION

Conversion disorder is characterized 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.

DEFINITION

Conversion disorder is an illness of symptoms or deficits that affect voluntary motor or sensory
functions, which suggest another medical condition, but that is judged to be caused by
psychological factors because the illness is preceded by conflicts or other stressors

The term conversion was introduced by Sigmund Freud, who, based on his work with Anna O,
hypothesized that the symptoms of conversion disorder reflect unconscious conflicts.

ATEIOLOGY

1. GENETICS:- There is very little evidence that the disorder runs in the families. It was
found that about 20% of first degree female relative have the disorder.
2. ORGANIC:-The disorder is related to organic i.e. nervous system. No exact pathology is
found.
3. PSYCHOANALYTIC THERAPY:- When there is current stress. People with this histrionic
personality display emotion readily and tend to react in demonstrative way that attracts
attention the emotionally charged ideas are lodge in the subconscious mind. when
repression fails, these idea threatens due to stress psychic energy is released and is
discharged in the form of dissociative symptoms.
4. LEARNING THEORY:- The patient communicates helplessness and gains support and
attention by focalizing the environment to avoid aggressive impulses. This reinforces the
patient to repeat the same symptoms for the secondary gain.

5. REFLEX MECHANISUM:-The disorder is the reflex reaction of the nerve system to

excessive stress. They could then be prolonged because of the gain or as a habit. The gain is
for the self or is deliberately cultivated by others for their gain.

5 OTHER: - Conversion symptoms are a type of primitive communication system since direct
is blocked between the people especially between the two loved person.

CLINICAL FEATURES:-

The patient is unconscious to the symptoms and gains some advantage. It has both physical
and mental symptoms.
1. DISORDER OF MOVEMENT:- Paralysis if involuntary muscle, tremor, tics, and disorder
of gait. But the muscles are capable of reacting when the patient’s attention is directed
elsewhere. Washing is absent showing no organic cause. Psychogenic tremor involves
whole limb. Psychogenic aphonic & mutism is seen.
2. DISORDER OF SENSATION: - The symptoms include anesthesia, paresthesia,
hyperesthesia and pain psychological blindness is seen in usual field .loss of smell and
taste.
3. GASTRO INTESTINAL SYMPTOMS:- Repeated vomiting, difficulty in swallowing, and the
constipation, retention of urine is also seen.
4. BRIQWET SYNDROM:-Many physical symptoms start from early 30 and last for many
years without evidence of physical disease.
5. MENTAL SYMPTOMS:- Psychogenic amnesia ,fatigue loss of memory ,but also wonders
away from usual surrounding, hysterical epilepsy or fits also seen pseudomentia,
psychogenic stupor, multiple personality disorder.

TYPES

A. Dissociative amnesia
B. Dissociative fugue
C. Dissociative identity disorder
D. Depersonalization disorder

A. DISSOCIATIVE AMNESIA:-Impairment of integration of memory will occur, dissociative

amnesia follow a traumatic or stressful life situation .there is sudden inability to recall
important personnel information particularly concerning the stressful life event the extent
of event is to great to be explained by ordinary forgetfulness. The amnesia may be localized,
generalized .selective or continuing in nature.

CAUSE

 Genetic link
 Neurophysiological dysfunction
 Traumatic event
 Stressful life situation
 Anxiety

CLICAL FEATURES

 Usually alert but clouding of consciousness

 Depressive symptoms
 Depersonalization
 Distress
 Trance state
 Regression
 INCIDENCE

 Common among young adults

 People who are exposed to war ,accidents or natural disaster
 Women experience more than male
DIAGNOSIS

 Complete medical history

 Physical examination, x-ray, other lab test like EEG, blood test for toxins and
drugs
 Psychological examination
 Referral to psychiatric unit

DSM-IV-TR Diagnostic criteria for Dissociative amnesia:-

A. The predominant disturbance is one or more episode of inability to recall important

personal information, usually of a traumatic or stressful
situation, that is too extensive to be explained by ordinary
forgetfulness.
B. The disturbance does not occur exclusively during the course of dissociative identity
disorder, dissociative fugue, posttraumatic stress disorder,
acute stress disorder, or somatization disorder and is not
due to the direct physiological effect of substance (e.g.
drug of abuse, a medication)or neurological or other
general medical situation (e.g.amnestic disorder due to
head trauma)
C. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important area of functioning.
DISSOCIATIVE FUGUE:-

When the ability to integrate identity is affected or fragmented, results in “dissociative fugue”.
It increases in stressful situations. It is psychogenic state, a sudden unexpected travel away
from home or work place, a feeling of new identity, unable to recall the past. self care is
maintained, new identity maintained for few days ,following recovery, they will not be able to
recollects the events that took place during fugue and leads simple life, confusion about
personal identity.

CAUSE

 Substance abuse
 Marital disharmony
 Occupational distress
 Wars
  Depression
DSM-IV-TR Diagnostic criteria for dissociative fugue:-

A. The predominant disturbance is sudden, unexpected travel away from home or one’s
customary place of work, with in ability to recall one’s past.
B. Confusion about personal identity or assumption of a new identity(partial or complete)
C. The disturbance does not occur exclusively during the course of dissociating identity
disorder and is not due to the direct physiological effect of substance (e.g. a drug of abuse,
a medication) or a general medical condition (e.g. temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important area of functioning.

DISSOCIATIVE IDENTITY DISORDER OR MULTIPLE PESONALITY DISORDER

A condition in which 2 or more distinct identities or personality state alternate in controlling the
patient consciousness and behavior .In multiple personality disorder, the person is
dominated by 2or more personality of which only one is manifest at a time one personality
is not aware of the other personality, suddenly one form to other form will change and the
behavior in each personality will be contrast of other, its own pattern of relating,
perceiving and thinking about them and environment .person behavior will be controlled
by these sub personalities. it may be a culture specific syndrome found in western society.

CAUSE

 An innate ability to dissociate easily

 Repeated episode of sexual abuse in childhood
 Lack of supportive or comforting person
 Physical; or psychological traumatic experience
 Absence of situational support
 Absences of adaptive copping ability
 Intense anxiety
 Negative role model
 Isolation from the community
MANIFESTATION

 Inadequate defense to handle the intense anxiety

 Usually the primary personality is religious and moralistic
 Sometimes the dominance will be changing, voice will have different sounds and
intelligence level varies
DIAGNOSIS

 Rule out physical conditions

 EEG to exclude seizures
 Dissociative experience scale and dissociative disorders interview for DSM-IV dissociative
disorders
 Hypnotic induction profile

DSM-IV-TR DIAGNOSTIC CRITERIA FOR DISSOCIATTIVE IDENTITY DISORDER

A. The presence of two or more distinct identities or personality states (each with it’s
own relatively enduring pattern of perceiving, relating to, and thinking about the
environment and self).
B. At least two of these identity or personality states recurrently take control of the
person’s behavior.
C. Inability to recall important personal information that is too extensive to be
explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effect of substance (e.g. black
out or chaotic behavior during alcohol intoxication )or general medication condition
(e.g. complex partial seizure )

DEPERSONALIZATION

“A persistent or recurrent alteration in the perception of the self to the extent that the
sense of one’s own reality is temporarily lost, while reality ability testing remains intact”

Depersonalization is a dissociative symptoms in which the patient feels that his/her

body is unreal, is changing or is dissolving .some dissociative disorder clients experience
depersonalization as feeling to be outside of there body or as watching a movie of
themselves .

AETIOLOGY

 CNS disease e.g. brain tumor, epilepsy

 Sever sensory deprivation
 Psychological conflicts
 Unpleasant emotions
 Emotional pain
MANIFESTATION

 The person experience depersonalization may feel mechanical, dreamy or

detached from body.
 Ego dystonic e.g. perceiving the limbs to be larger or smaller than the normal
 The experience cause significant impairment in social or occupational
functioning makes distress.

DSM-IV-TR DIAGNOSTIC CRITERIA FOR DEPERSONLIZATION DISORDER

A. Persistent or recurrent experience of feeling detached from, and as if one is an an

outside observer of ,ones mental process or body (e.g. feeling like one
is in a dream )
B. During the depersonalization experience, really testing remains intact.
C. The depersonalization cause clinically significant distress or social occupation or other
important area of functioning.
D. The depersonalization experience does not occur exclusively during the course of
another mental disorder.
MANAGEMENT

The management of dissociative and conversion disorder involve a comprehensive medical,

psychiatric and psychosocial evaluation of the patient.

A throaty initial medical and neurological assessment is also crucial relevant investigation (like
urinary drug screen to rule out drug use, EEG to rule out complex partial
seizure, IQ testing to rule out borderline intellectual functioning) should
be done whenever indicated.

REASSURANCE IS THE BEST METHOD OF TREATMENT

 Psychotherapy
 Behavior therapy
 Abreaction
 Drug therapy
 Hospitalization
 Family and marital therapy
 Group therapy

1. PSYCHOTHERAY
Supportive psychotherapy with reassurance helps the patient to come out of the symptoms.

2. BEHAVIOUR THERAPY
Modification of behavior by the therapy alone has little value but conjoint with family
therapy helps.

3. ABREACTION
Helps the patient to take up the responsibilities gradually abreaction is bringing to conscious
,awareness ,thought, affects and memories for the first time, with or without the use of
drugs this may be achieved by :-

 Hypnosis
 Free association
 Drugs like intravenous barbiturates like thiopentone (pentothal),ketamine, diazepam

4. DRUG THERAPY
Drug treatment has a very limited role in dissociative (conversion) disorders few few
patients have anxiety and may need short treatment with benzodiazepines .
 Benzodiazepines alprazolam, chlordiazepoxide, diazepam are given to reduce anxiety,
buspirone is also given for minimal side effect.

To reduce other side effects antihistamine is added.

5. HOSPITALIZATION
Admission to the inpatient setting can be helpful .if the symptoms are disabling or alarming
to the family. a short term admission can remove the patient from the stressful
situation .secondary gain must be minimized.

6. GROUP THERAPY
Participation in a group setting may diminish to the patient’s sense of lonleness,make
available a secure place to discuss traumatic matter that patient without dissociative
disorder may not be able to tolerate, to study interpersonal relationship, to develop more
functional interactions, and learn more about cooping mechanisms.

7. FAMILY AND MARITAL THERAPY

Working simultaneously with the patient’s family (and spouse, if married)is an important
component of the management. Direct communication with the family members will also
because the opportunities for manipulation and misunderstanding.

NURSING MANAGEMENT

A complete history collection gives the cause of the disorder. Based on the assessment,
nursing management is planned.

Nursing diagnosis:-
1. Altered family process related to dysfunctional behavior
Intervention
 Meet the family member
 Teach family to communicate clearly and honestly
 Encourage family member to evaluate communication patterns periodically
 Refer to outside agencies, if needed.
 Reassure the family by providing safety and security

2. Coping ineffective individual related to personal Vulnerability.

Interventions

 If possible, assign primary nurse to patient

 Discourage dependent behavior by assisting patient
 Only when necessary, provide positive
 Reinforcement for independent behaviors.
  Help patient recognize and feel good about positive personnel qualities &
accomplishments.
 Help the patient analyze current situation & evaluate
 Effectiveness of coping strategies
3. Personal identity disturbances related to lowered self –esteem.

Intervention

 Help the patient identity values, beliefs, hopes, dreams, skills and interests.
 Listening to patient’s personal values and belief, but remain Nonjudgmental, even if his
value and beliefs differ from your own.

4. Self care deficit related to dissociative disorder .

Intervention :

 Encourage the patient to perform normal ADL to her level

 Positive reinforcement
 Demonstrate & discuss with the patient and plan the coping strategies to overcome
the anxiety
 Administer tranquillizers to reduce anxiety.

BIBLIOGRAPHY

1. K.lalitha (2007).mental health and psychiatric Nursing an Indian perspective .(1 st

edition).Ananda.m ,ramesh m. Bangalore.

2. Kaplan & shaddock, s.(2005) .comprehensive textbook of psychiatric Nursing.(eighth

edition) .USA.Lippincott Williams & Wilkins.

3. http:\www.google.come.dissociative conversion disoreder.

4. K.P.Nirja,(2008). essential of mental health and psychiatric Nursing .(first edition).New

Delhi .Jaypee Brother medical publishers.

5. Kaplan & shaddock’s synopsis of psychiatric. page no. 676-79

 PADMASHREE INSTITUTE OF
NURSING

Teaching practice ON
“DISSOCIATIVE CONVERSION
DISORDERS”

SUBMITTED TO:

MR. D.E.BHASKARARAJ

HOD DEPARTMENT OF PSYCHIATRIC NURSING

PADMASHREE INSTTUTE OF NURSING

SUBMITTED BY:

Mr. DEEPAK.K

I YEAR M.Sc. NURSING

PADMASHREE INSTTUTE OF NURSING

SUBMITTED ON: 22 /10 / 2009