DISSOCIATIVE DISORDER

DEFINITION

Conditions that involve disruptions or breakdown of memory , awareness, identity, perception without any medical or neurological disorder but that occur in presence of psychosocial stress.

CLINICAL FEATURES

1.sudden onset 2.development of symptoms in the presence of a significant psychosocial stresses. 3.A clear temporal relationship between stressor and development or exacerrbation of symptoms. 4.La-belle-indifference- which is a lack of concern towards the symptoms ,despite the apparent severity of the disability produced.

4. Patient do not intentionally produce symptoms 5. There will usually a secondary gain 6. Physical examination and lab investigations will be normal.

CLASSIFICATION

1.Dissociative motor disorders. 2.Dissociative anesthesia and sensory loss. 3.Dissociative convulsions. 4.Dissociative amnesia . 5.Dissociative fugue. 6.Multiple personality disorder. 7.Trance and possession disorders 8.Other dissociative disorder Gansers syndrome

DISSOCIATIVE MOTOR D/O

It involves either paralysis or abnormal movements or gait disturbance. Symptoms involved will depend on the patients knowledge of CNS . Abnormal movements range from tremors , choreiform movements , convulsive movements. These movements occur or increase when attention is directed towards them and disappear when patient watched unobserved.

Gait wide based, jerky , staggering,dramatic , and irregular gait with exaggerated body movements. Examination normal

DISSOCIATIVE SENSORY D/O

Clinical features: 1. Glove and stocking anesthesia usually limiting at the wrist and ankles. 2 .Hemianesthesia. 3. Blindness- u/l or b/l. 4. Deafness.

Sensory disturbances are inconsistent with the anatomic patterns expected but is usually based on patients knowledge of that illness. In bilateral blindness the patient dont injure himself by walking into obstacles . In unilateral blindness the pupillary reflex of the affected eye is normal. Most common is mixed presentation with both motor and sensory component.

DISSOCIATIVE CONVULSIONS

Earlier known as hsyterical fits or pseudoseizures. Dissociative convulsions characterised by convulsive movements and partial loss of consciousness.

Clinical features
1.Attack pattern 2.Place of occurence 3.Time 4.Tongue bite 5.Urinary and faeces incontinence 6.Speech 7.Duration

Epileptic seizures Dissociative convulsions

Stereotyped ,known clinical patterns. Anywhere Anytime , even during sleep present Can occur No verbalization during seizure 30-70sec Purposive body movements. Mostly indoors or at safe places. Never occur during sleep Usually absent , lip and cheek bite Very rare Verbalization may occur during fit. 20- 800 sec

Clinical features
8.Head turning 9.Eye gaze 10.Amnesia 11.Neurological signs 12.Postictal confusion 13.EEG- Interictal and ictal 14. stress 15.S.prolactin

Epileptic seizures
u/l Staring look complete Present Present Abnormal Present in 25% Increased in postictal period

Dissociative convulsions
Side to side turning Avoidant gaze partial absent absent absent Most common normal

DISSOCIATIVE AMNESIA

More common in adolescent and young adults. Females more than males following stressful or traumatic events. During the amnesic period there may slight clouding of consciousness .In the post amnesic period the awareness of disturbance of memory present.

TYPES OF DISSOCIATIVE AMNESIA:

1. Circumscribed amnesia: - is most common type in which there will be inability to recall all the personal events during a circumscribed period of time . 2. Selective amnesia: - less common type in this there is inability to recall only some selective personal events while other events during that period may be recalled.

3.Continous amnesia: - rare type. - there is an inability to recall all personal events following the stressful event till the present time. 4.Generalised amnesia: - very rare. - there is an inability to recall the personal events of the whole life ,in the face of a stressful life event.

DISSOCIATIVE FUGUE :
- episodes of wandering away usually away from home. - during this episode the person adopts a new identity with complete amnesia for the earlier life . - sudden onset , often in presence of stress . - termination too is abrupt and is followed by amnesia for the episode , but with recovery of memories of earlier life

D/D:
complex partial seizures In this there is no assumption of a new identity , confusion or disorientation is present during the episodes and the episodes are not linked to any precipitating stress.

MULTIPLE PERSONALITY DISORDER

- The person is dominated by two or more

personalities,of which one only manifest at a time . - Each personality has full range of higher mental functions and performs complex behaviour patterns. - Usually one personality is not aware of the existence of the others , there is amnestic barrier between the personalities . -

TRANCE AND POSSESSION D/O:

- characterised by control of persons personality by a spirit durind episodes . - usually person aware of the existence of other

GANSER SYNDROME:
- commonly found in prison inmates
- vorbeireden ( approximate answers), the answers are wrong but show that the person understands the nature of the question asked.

TREATMENT

1.Behavior therapy: - These patients symptoms increase with

focus of attention, so the symptoms should not be unduly focussed on .Any improvement in symptoms should be encouraged . - when there is acute symptoms its prompt removal may prevent habituation and future disability.

A. Strong suggestion to return to normalcy. B. Aversion therapy by liquor ammonia , aversive electric stimulus , pressure just above the eye ball or tragus of ear in resistant cases - Problems with aversion therapy is it tends to get over used, may harm the patient . C. Amplification of suggestion with hypnosis , i.v diazepam , i.v thiopentone .

2. Psychotheraphy with Abreaction: - Abreaction is bringing to the conscious awareness , thoughts , affects and memories for the first time. - This is achieved by hypnosis , free association , iv thiopentone or diazepam.

3.Supportive therapy This is needed when conflict have become conscious and have to be faced in routine life. 4.Psychoanalysis. 5.Drug therapy- iv thiopentone or diazepam in abreaction.