1. 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.

2. 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

4. 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

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

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

8. 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

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

11.  Psychological Amnesia Identity confusion Trance “Possession” states

12. 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

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

15. 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

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

17. 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

19. 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

21. 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

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