DR.M IMRAN AFZAL MBBS,DPM (DIPLOMAT PSYCHOLOGICAL MEDICINE) C.PSYCH (MISSOURI) USA DAYTOP GRADUATE (USA) CONSULTANT PSYCHIATRIST PUNJAB INSTITUTE OF MENTAL HEALTH, SHADMAN, LAHORE.

DISSOCIATION (CONVERSION) DISORDER FORMERLY HYSTERIA  Disorder of sudden dramatic symptoms  Inconsistent with known diseases  “Unconscious” process---not malingering  Symptoms may present singly or en masse

EPIDEMIOLOGY  Incidence reported as 22 per 100,000  5 to 15 % of psychiatric consultations in a general hospital  Ratio of men to women is 1 to 2  Men mostly involved in occupational and military accidents  Common age is adolescents and young adults

 Common among rural populations, little educated persons, those with low IQ, low socioeconomic groups and military personnel exposed to combat situations

CO MORBIDITY  Commonly associated with major depressive disorder, anxiety disorders and schizophrenia

ETIOLOGY  Psychoanalytic factors Conflict is between an instinctual impulse an the prohibitions against its expressions  Biological factors Brain imaging shows hypo metabolism of the dominant hemisphere and hyper metabolism of the non dominant hemisphere Excessive cortical arousal

 Neuropsychological tests reveal cerebral impairments in verbal communication, memory, vigilance, affective incongruity and attention

 Psychological Amnesia Identity confusion Trance “Possession” states

CLINICAL FEATURES  Paralysis  Blindness  Mutism SENSORY SYMPTOMS  Anaesthesia  Paresthesia  Stocking and glove anaesthesia of the hands and feet  Hemi anaesthesia of the body along the midline

MOTOR SYMPTOMS  Abnormal movements (choreiform,tics,jerks)  Gait disturbance  Weakness  Paralysis

SEIZURE SYMPTOMS  Pseudo seizures are common Pupillary and gag reflexes are retained after pseudo seizures No post seizure increase in prolactin levels  Co existing epileptic disorder

ASSOCIATIVE FEATURES  Primary gains  Secondary gains Avoiding difficult life situations Receiving support and assistance Controlling others’ behaviour  La belle indifference

DIFFERENTIAL DIAGNOSIS  Epileptic fit  Physical conditions causing similar symptoms  Neurological illnesses esp. multiple sclerosis,myopathies guillain-barre syndrome,early neurological symptoms of AIDS  Atypical depression  Unexplained somatic complaints  Anxiety disorders

MANAGEMENT  Good history taking  Advice and support to the patient and family Symptoms have no clear physical cause Can be brought about by stress Symptoms usually resolve rapidly leaving no permanent damage

PSYCHOLOGICAL HELP  Encourage the patient to acknowledge recent stresses  Give positive reinforcement  Take brief rest from stress before returning to usual activities  Advise against prolonged rest or withdrawal from activities

MEDICATION  Anxiolytics  Use of ammonia ??  Anti depressants  Referral to psychiatric facility