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Dissociative disorders is a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations and control of bodily movements.
• A clear temporal relationship between the onset of a psychosocial stress or and the development of symptoms. • Sudden onset of symptoms. • Symptoms are not intentionally produced • There is usually secondary gain. • Detailed physical exam and investigations do not reveal any abnormality • Labelle indifference.
* 1% of population
* Females > male * More in developing & underdeveloped countries. * More in uneducated and low socio-economic group
Dissociative disorders can affect
Higher mental functions Motor system or Sensory system
It is important to remember that symptoms can not be explained by any neurological illness. Higher mental functions Amnesia Fugue Multiple personality Trance & possession state.
Dissociative Amnesia: Patient suddenly loses memory of certain traumatic events. Dissociative Fugue: Patient wanders away from home and takes up new identity. He completely forgets who he was and what he was doing.
Multiple personality: Patient keeps on alternating between two or more personalities of which only one is being manifest at one time. Trance and possession disorders: Person says that he has been possessed by a spirit or devi.
Dissociative Stupor: Patient becomes immobile, does not respond to external stimuli. Speech and spontaneous purposeful movements are completely lost. However breathing, muscle tone, eye movements are not affected. Patient is neither unconscious or asleep.
Dissociative motor disorders:
(a) Paralysis: Monoplegia, paraplegia or quadriplegia, Patient’s weakness changes, when he is being examined reflexes are normal, planters (b) Abnormal movements: can be tremor, chorea. These movements either occur or when attention is directed towards them and may disappear when patient is unobserved. These movements do not fit typical clinical picture.
(c) Dissociative Convulsion
1. Attack pattern
Epileptic seizure Dissociative convulsion
Stereotyped, known clinical pattern Anywhere Complete loss of consciousness 3-5 mins Any time Absence of any established clinical pattern, purposive body movements occur Usually indoor or safe places Partly impaired Longer duration Never occur on sleep Very rare Very rare Side to side Resist eye opening
2. Place of occurrence 3. Loss of consciousness 4. Duration 5. Time of day
6. Incontinence of urine Can occur and focus 7. Serious injury or tongue bite 8. Head turning 9. Eye gauze Can occur Unilateral Staring if eyes are open
Pupillary reaction to light
Covneal reflex Amnesia Planters Postictal Confusion
+ve Often partial
(d) Gait: Wide based, staggering Jerky, dramatic, exaggerated when observal
Dissociative Sensory disturbances Anaesthesia - Glove and stocking Hemianaesthesia Blindness – Unilateral or bilateral Deafness - rare
STRESS RELATED DISORDERS
In these disorders , symptoms arise always as a direct consequence of the severe acute stress or continued trauma. These disorders are regarded as maladaptive responses to severe or continued stress that interfere with successful coping mechanisms and thus lead to problems in social functioning.
1. Acute stress Reaction Immediate and clear temporal relationship between an exceptional stressor and onset of symptoms. Stressors like death of a loved one, natural catastrophe, accident, rape etc. More likely to occur in presence of physical exhaustion and in extreme of age. More in females and people with poor coping skills.
Symptoms range from “dazed” condition, narrowing of attention, inability to comprehend stimuli and disorientation. This state may be followed either by further withdrawal from the surrounding (to the extent of dissociative stupor) or by agitation or over activity. Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present.
The symptoms usually appear within minutes of the impact of stressful stimulus or event and disappear within 2-3 days (often within hours) Partial or complete amnesia for the episode may be present. Treatment: Removal of the patient from stressful environment. Benzodiazepines in case of agitation.
2. Adjustment disorders: States of subjective distress and emotional disturbance usually interfering with social functioning and performance and arising in the period of adaptation to a significant life change or to the consequences of a stressful life event.
Symptoms: include:Depression, anxiety, or mixture of anxiety and depression, a feeling of inability to cope, predominate disturbance of conduct. Onset is usually within 1 month of the occurrence of stressful event or life change and the duration of symptoms does not usually exceeds 6 months.
Treatment: Supportive psychotherapy Coping skill training Drug treatment may be needed for the anxiety (benzodiazepines) and for depression (anti depressant)
3. Post traumatic stress disorders (PTSD)
This arises as a delayed response to a stressful event or situation of exceptionally catastrophic or threatening nature (natural or man made disaster, combat, serious accident, witnessing violent death of other or being the victim of torture, terrorism, rape or other crime)
Clinical features: Typical symptoms
• Recurrent or intrusive re-experiencing of the traumatic event either in memory flashbacks or dream.
• Intense distress at exposure to events that resemble the original event. • Effort are made to avoid thoughts and feelings associated with the trauma. • Partial or complete amnesia for the event. • Feeling of numbness and detachment from other people and unresponsiveness to surroundings. • Anhedonia • Increased arousal, hyper vigilance and enhanced startle reaction.
• Anxiety and depression are commonly associated with above symptoms and signs. • There may be insomnia. Onset follows the trauma with a latency period which may range from a few weeks to six months. Course and Prognosis: Majority of PTSD patients show complete recovery. Few may show chronic course.
Management: * Pre disaster management * Post disaster management * Psychotherapy * Pharmacotherapy
SOMATOFORM DISORDERS Physical symptoms without organic basis. Physical symptom suggest physical illness (hence somatoform) for which no demonstrable organic findings.
Somatoform disorders are divided into:1) Somatisation disorder: a) Multiple somatic symptoms involving more than two systems. b) Long duration > 2 yrs c) Symptoms can not be explained medically 2) Hypochondrial disorder: Conviction of a disease in the absence of it.
• The emphasis is on the individual symptoms. • Symptoms are changing • Patient demands treatment and removal of symptom • Excessive drug use.
• The emphasis is on underlying disease. • Restricted to one or two systems. • Wants investigations to settle diagnosis. • Fear drugs and their sick effect.
3) Somatoform autonomic dysfunction: Symptoms refer to organ systems directly under autonomic control. Cardiovascular palpitation. G.I.T. a) Upper Aerophagy Hiccups b) Lower flatulence Irritable bowl Respiratory System Hyperventilation Genitourinary system Dysuria
4) Persistent pain disorder: Preoccupation with persistent, severe and distressing pain in the absence of physical findings to account for the pain. Clear psychogenic factors should be present.
Personality is defined as a deeply ingrained pattern of behavior relating to thinking about oneself and the surrounding behaviour. Personality traits are normal, prominent aspects of personality e.g. shy, social, hardworking etc. Personality disorders result when these personality traits become abnormal. i.e. when it disrupts the personal life of the individual or show deleterious effects on the society or the family.
Although personality disorders are usually recongnisable by early adolescence, they are not diagnosed before early adulthood.
1. Paranoid personality disorder: These patients show excessive suspiciousness. Does not trust friends or family members. They get involved in litigation on small issues.
2. Schizoid personality disorder: * Patient is aloof by nature * No desire for close relationship * Does not show emotional attachment to friends or family members. * Indifferent to praise or criticism. 3. Dissocial Personality Disorder: * Disregard for rules of society * Repeated breaking of laws by lying, or violence. * No remorse or guilt when caught.
4. Emotionally unstable personality: * Tendency to act impulsively * Emotionally instable * Prone to outbursts of violence * Has chronic feelings of emptiness * Short lasting relationships. 5. Histrionic personality Disorder: * Excessive emotional and attention seeking behaviour. * Unable to develop deep relationship.
6. Anxious personality disorder: * Shy and socially inhibited * Feelings of inferiority * Hypersensitive to rejection 7. Dependent personality disorder: * Excessively dependent on others. * Not able to function alone. * Can not take any decision alone. * Submissive
8. Anankastic personality disorder: * Preoccupied with orderliness and cleanliness. * Lack Flexibility * Rigid about morality and ethics * Stingy and stubborn
* Paranoid * Schizoid * Dissocial
* Emotionally Unstable * Histrionic
* Anxious * Dependent * Anankastic
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