CONVERSION DISORDER (DISSOCIATIVE DISORDER)

Introduction
In the ancient time, the condition was thought to result from movement of the
uterus from its normal position and so the name “Hysteria”. The term hysteria meaning
womb or uterus. Only in the seventeenth century English physician suggested that
hysteria was caused by disorder of the brain. Freud suggested that hysteria was caused by
emotionally charged ideas which had become lodged in the unconscious of the patient at
some previous time and which were excluded from conscious awareness by a process
called repression. Freud also suggests that the repressed ideas were sexual. In recent
years the term ‘hysteria’ avoided in view of its many and varied meaning. The term
“conversion” is using because psychosocial stress or strong emotions are expressed in the
form of physical symptoms. Conversion disorder is also known as dissociative disorder.
The physical symptoms of conversion disorder reduce anxiety, in the patient. patient also
gets increase care and decreased responsibility after becoming sick. This disorder is more
common in female than male.

Definition
Conversion disorder is a psychoneurotic disorder in which repressed inner conflicts are
unconsciously converted or transformed into physical symptoms that have no organic
basis ie. Paralysis, blandness, loss of sensation , seizure or fits.

Causes
Feeling of sadness or unhappiness __________ unable to express_____________
repressed the conflicts ___________ anxiety produces __________converted in to
physical symptoms.

Some important features of conversion disorder

1. The symptoms are produced because they reduce the anxiety of the patient by
keeping the psychological conflict out of conscious awareness, a process called as
‘primary gain’.
2. These symptoms of conversion are often advantageous to the patient. For example
a women who develops psychogenic paralysis of the arm escapes from taking care
of child or elderly relatives. Such advantage is called as ‘secondary gain’.
3. The patient does not produces the symptoms intentionally.
4. The patient shows less distress or shows lack of concern about the symptoms,
called as ‘belle indifference’.
5. Physical examination and investigation do not reveal any medical or neurological
abnormality.

Sign and symptoms

Behavioral characteristic
Dramatization.
Exhibitionism.
Narcissism.
Emotionalism.
Manipulativeness.
Suggestible and childlike behavior.

Motor symptoms
Tremors.
Convulsion.
Mutism but patient can cough.
Aphonia but patient can whisper.
The patient can control his leg movement while sitting or lying but can not control and
walk properly.

Sensory symptoms
Diminish ability to feel pain.
Partial loss of sensitivity or excessive sensitivity.

Visceral symptoms
A feeling of lump in throat.
Nausea, vomiting and chocking sensation.

Different phenomena comes under this disorder

1. Dissociative amnesia
This is the commonest clinical type dissociative conversion disorder occurring mostly in
adolescent and young adults ( more in female). It is characterized by a sudden inability to
recall important personal information ( amnesia) . particularly concerning stressful or
traumatic life events. Most often. Dissociative amnesia follows a traumatic or stressful
life situation. The amnesia may be localized, generalized, selective or continuing in
nature.

2. Dissociative fugue
Psychogenic fugue is a sudden, unexpected travel away from home or workplace, with
the assumption of a new identity and an inability to recall the past. The onset is sudden,
often in the presence of severe stress. The course is typically a few hours to days and
sometimes months.

3. Dissociative stupor
In this patients are motionless and mute and do not response to stimulation, but they are
aware of their surroundings. It is rare condition.

4. Ganser’s syndrome
Ganser’s syndrome is a rare condition with four features of giving “approximate
answers” to question designed to test intellectual functions, “ psychogenic physical
symptoms”, “hallucination”, and “apparent clouding of consciousness”.
5. Multiple personality disorder ( dissociative identity disorder)
In this disorder, the person is dominated by two or more personality of which only one is
manifest at a time. Usually one personality is not aware of the existence of the other
personality. Each personality has a full range of higher mental functions and perform
complex behavior pattern. Transition from one personality to another is sudden, and the
behavior usually contrast strikingly with the patient’s normal state.

6. Trance and possession disorder

This disorder is very common in INDIA. It is characterized by a temporary loss of both
the sense of personal identity and full awareness of the person’s surroundings. When the
condition is induced by religious rituals, the person may feel taken over by a deity or
spirit. The focus of the immediate environment and there is often a limited but repeated
set of movement postures utterances.

7. Dissociative motor disorder

It is characterized by motor disturbance like paralysis or abnormal movement. Paralysis
may be a monoplegia, paraplegia or quadriplegia. The abnormal movement may be
tremors, choreinform movement or gait disturbance which increase when attention is
directed towards them. The examination reveals normal tone and reflexes.

8. Dissociative convulsion ( hysterical fits of pseudo – seizures)

It is characterized by convulsive movement and partial loss of consciousness. Differential
diagnosis with true seizure is important.

9. Dissociative sensory loss and anesthesia

It is characterized by sensory disturbance like hemianesthesia, blindness, deafness and
glove and stocking anesthesia ( absence of sensation at wrist and ankles).

Diagnosis
 Patient presents with clinical features like trance, pseudo convulsion, pseudo
paralysis, visual disturbance or amnesia. The sudden onset of deliberating
symptoms.
 There is no evidence of physical illness that might explain the symptoms.
 There is evidence of psychological causation, in the form of clear association in
time with stressful event and problem or disturbed relationships.
 A lack of concern that is usually associated with severe symptoms. symptoms
must cause significant distress and impairment is social work or other setting.
 The symptoms are not intentionally produced, meaning there is no voluntary
control over symptoms as occur in malingering. In malingering that involves
faking symptoms for external gain.
 Difference between epileptic and pseudo/ hysterical seizure.
Clinical points Epileptic seizure
History of fall and injury Present
Time and day Anytime. Can occur during
sleep also.
Movement of the limbs Regular and rhythmic.
Every attack is same as
previous.
Tongue bite Usually present
Incontinence of urine and May be present
faces
During attack pupils Dilated
Automatic arousal Present
Planter reflex during an Up going ( extension)
attack
Duration of fits 1-5 min ( usually 30-70
seconds)
Place of attack At any place on the road,
toilet.
Duration of illness Month of years.
Aura May be present.
Speech No verbalization
Head turning Unilateral
Eye gaze Staring if eyes are open
Amnesia Complete
Precipitating cause Rare
Post – ictal confusion, Often seen
drowsiness, sleep
Serum prolactin Increased in post ictal
period (15-20) minute after
seizure, returns back to
normal in one hours.
EEG – iner ictal Usually abnormal
Pseudo/hysterical seizure
Absent
Never occurs at during
sleep.
Irregular and rhythmic
attack are differ.
No
No
Normal
Only after the intervention
by other.
Normal ( down going).
Variable may be many
hours (20-80 second).
At specific places only.
Few days to month
Not present.
Verbalization may occur
during the fit.
Side to side turning.
Avoidant gaze.
Partial.
Common, emotional and
stress related.
No
Usually normal
Usually normal
Epidemic hysteria
Occasionally, conversion disorder spreads with in a group of people as an “epidemic” in
closed group of young women or men for example in a hostel, in the class room or in the
picnic party etc. Usually anxiety has been among the members of a group. The epidemic
starts in one person who is highly suggestible and then other cases appear. The symptoms
are variables but fainting and dizziness are common presenting symptoms.

Prognosis
Symptoms usually last for days to weeks and may resolve spontaneously. Usually the
symptoms are itself is not life threatening. However the development of complication can
be dangerous.

MANAGEMENT
Psychotherapy
 Individual psychotherapy.
 Family psychotherapy.
Behavior therapy
 Aversion therapy.
 Operant Conditioning .
Drug therapy
Drug has limited role. Short term treatment with benzodiazepines or beta blockers. If
patient has depression also use of antidepressants medicine.
Stress reduction programme
Yoga
Meditation

NURSING MANAGEMENT

1. Assess physician’s on going assessment laboratory reports and other data to rule
out organic pathology.
2. Identify primary and secondary gain and encouraging normal behaviour.
3. Encourage patient to perform self care activities as independently as possible.
Intervene only when patient requires assistance.
4. Withdraw attention if the patient to verbalize fears and anxieties.
5. Positive reinforcement for identification or demonstration of alternatives adoptive
coping strategies.
6. Identify specific conflicts that remain unresolved and assist patient to identify
possible solutions.
7. Assist the patient to express her feeling and emotional conflicts. Verbal
expressions of emotional pain speeds up recovery, so patient should be encourage
to talk during therapy.
8. Establish trusting relationship with the patient.
9. Patient’s comfort and safety are nursing priorities.
10. Essential information for patient and family. Physical symptoms have no serious
affect in patient it is caused by stress. Giving positive reinforcement is necessary
for improvement is necessary.