28 - Dissociative (conversion) disorders

Dissociative (conversion) disorders

© SPMM Course Posttraumatic stress disorder

The term PTSD denotes an intense prolonged and sometimes delayed reaction to an intensely stressful event. The essential features are hyperarousal, re-experiencing of aspects of the stressful event and avoidance of reminders. The principal symptoms of PTSD include Hyperarousal o Persistent anxiety o Irritability o Insomnia o Poor concentration Hypervigilance due to re-experiencing and enhanced startle response o Intrusions o Recurrent distressing dreams o Intensive intrusive imagery (flashbacks, vivid memories) o Difficulty in recalling stressful events at will Avoidance o Avoidance of reminders of the events- Efforts to avoid thoughts, feelings, or conversations associated with the trauma. Efforts to avoid activities, places, or people that arouse recollections of the trauma o Detachment-Feeling of detachment or estrangement from others o Emotional numbness o Diminished interest in activities (anhedonia) Both ICD-10 and DSM-IV require 2 or more persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor) to diagnose PTSD. PTSD should start within six months of the trauma. In a small number of patients the onset is delayed i.e. after six months – termed  as  ‘probable PTSD’; in others the course may be chronic

6 months. Enduring personality changes are also reported following such trauma. In DSM-IV, a 3-months threshold is used to define chronic PTSD. Type 1 trauma refers to a single sudden catastrophic event e.g. accidents or rape. Type 2 trauma refers to a chronic repetitive insult against which the individual has no defence e.g. sexual abuse.

Dissociative (conversion) disorders Under this chapter in ICD-10 dissociative amnesia, fugue, trance/possession and disorders of movement/sensation (motor disorders, convulsions, anaesthesia/sensory loss) are included. DSM-5 AND PTSD The stressor criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. The need for subjective response with intense fear, helplessness, or horror is removed now. Along with the symptom clusters of reexperiencing and hyperarousal, the avoidance/numbing cluster is split into two. So now there are 4 clusters. Irritable, reckless or self-destructive behaviour is added to the description of arousal symptoms. Diagnostic threshold is lowered for children. In addition, a separate PTSD criterion has been added for children less than age 6.

© SPMM Course Dissociation is referred to as loss of integration among memories, identity, sensations and movements. It occurs closely in time with trauma. Theoretical concepts such as unconscious motivation or secondary gain are not used to describe this condition in ICD 10. Dissociation starts suddenly and terminated abruptly within weeks to months, Treatment is difficult in patients in whom it remains chronic (i.e. nearly a year). The concept of dissociative amnesia is centered on the loss of memory for important recent events, which is partial, patchy and selective. The characters of dissociative amnesia are o Episodic memory loss: retrograde only – no anterograde deficits. o Amnesia is for events that happened in a discrete period of minutes to years o The problem is not vague or inefficient retrieval but the strikingly complete unavailability of memories which were generally formed and were previously accessible. These events are traumatic or stressful. Amnesia can occur as a part of a dissociative fugue as well. In fugue purposeful journey away from home or   one’s   usual   base occurs. Self-care is usually maintained despite   ‘getting   lost’. Sometimes new identity can be assumed, and amnesia is present for past identity during the fugue; on recovery amnesia may be present for the fugue episode itself. As there is no cognitive impairment, the behaviour is usually normal. Perplexity and la belle indifference are frequent. Trance is a dissociative state where narrowed consciousness and limited but repeated movements are seen. Diagnosis of trance is made only if it is involuntary and not a culturally appropriate, intended practice. In addition, the trance states must be intrusive on activities of life and occur outside culturally sanctioned situations. Note that Temporal Lobe Epilepsy and head injury can also cause ‘organic’  trance.

Conversion / hysterical disorder is called a dissociative disorder of motor movement and sensations. The degree of disability in this disorder is very variable. La belle indifference is not universal, but common in conversion disorder. Close friends or relatives might have had the actual organic illness whose symptoms are present in a subject with conversion disorder. A milder and transient variety is seen in adolescent girls. Both Ganser syndrome and twilight states are included in dissociative states according to ICD-10. In DSM-IV, under dissociative disorders, only amnesia, fugue, dissociative identity disorder (multiple personalities), and depersonalization disorder are included. Conversion disorders and DSM-5 AND DISSOCIATIVE DISORDERS Depersonalisation disorder is now renamed as depersonalization/derealization disorder. Fugue is now a specifier for amnesia; not a separate diagnosis Dissociative identity disorder now includes pathological possession syndromes seen in some cultures. Both observed and reported changes in personality are considered in the