DISSOCIATIVE DISORDER

13 year old female patient studying in 9th std

hailing from Deshnur Bhailungal Taluk
INFORMENT- FATHER -HISTORY RELIABLE AND
ADEQUATE
PATIENT- HISTORY NOT RELIABLE OR ADEQUATE
TDI- 45 DAYS
Course- continuous
NO PRECIPITATING FACTOR COULD BE ELICITED
ACCORDING TO PATIENT- C/0 FEARFULLNESS
ACCORDING TO ATTENDER-
Abnormal behaviour – 45 days
Talking to self – 2 days
HOPI
Patient was apparently normal 45 days back when
she started complaining of being fearful in the
night while washing dishes, the next day patient
started talking to self about events in her school
that happened in the past for example that girl is
not good and that teacher is not good, over the
next few days patient started increasing her self
muttering, the content of which would range from
past incidents to mimicking known person’s voice,
the self muttering would stop abruptly and she
would cry and call her parents and then complian
to them that she was being feafull, when parents
questioned about why she was talking to self,
patient would say that she was not aware of it,
after about a week patient stopped responding to
her name and when asked her name she would
reply she is “Soni” ( the name of her deceased
cousin ageed 27 years who died due to prolonged
illness 2 years ago), patient would modulate her
voice ranging from a toddler to a grown up adult
and would become restless and start screaming as
to what was happening to her, patient would have
disturbed sleep wherein she would be self
muttering in the night and start spitting saliva, her
parents had taken her to faith healers to various
temples like kumpi siddeshwar, Lakshmi temple
and deshanur temple, her symptoms did not
improvePatient after 15 days of the onset of
symptoms was brought to Bims Hospital and was
admitted in the paediatrics Department, wherein
she was given non-psychiatric management and
her symptoms resolved after 15 days of admission
and she was discharged, patient after discharge
started attending school but was withdrawn
socially, after 10 days patient started claiming she
is Kavitha, she stopped responding to her name
and would often become restless and start
collecting saliva in her mouth, she refused to
swallow the same and would spit it out, patient
would say that she is Kavitha and is studying in 5th
std. Patient stopped going to school and the
abnormal behaviour worsened, father reports the
abnormal behaviour being present even when no
one was looking at her although the intensity of
the symptoms increased when others were
present. she was brought and admitted to BIMS
pediatric ward and reffered to psychiatric
department wherein treatment was started and
patient’s abnormal behaviour and stereotypical
act of spitting saliva improved, patient after
discharge started going to school. According to
the father the patient was socially withdrawn
from them and would not talk much to her family
as she previously used to.
From past 2 days patient started talking to self
again about past incidents and changing the tone
of her voice mimicking that of a toddler, patient
would become easily startled to sudden noises
and would start crying and becoming restless.
According to the father when they reprimanded
or scolded her for the abnormal behaviour patient
would stop it abruptly and then restart with
greater intensity as before.
Patient is eating well and sleeping well.
Bowel and bladder habits are regular.
NEGATIVE HISTORY
No history of head injury fever epilepsy loss of
consciousness
No history of thoughts being heard or controlled
by others
NO History of hearing of voices, suspiciousness
No history of low mood decreased interest in
activities
NO History of any substance abuse
NO History of palpitations Associated with
breathing difficulty or sweating
No history of repeated intrusive thoughts or acts,
repeated checking of doors or repeated washing
of hands

PAST MEDICAL HISTORY

Patient was admitted on 28th June in Bims
pediatric department and was treated for
dissociative disorder managed conservatively, she
was discharged on 6/7/23
Patient was again admitted on 17/7/23 and was
treated for dissociative disorder, wherein patient
was referred to psychiatry department and was
started on T.olanzapine 2.5mg OD,
TREATMENT HISTORY:
Patient was started on T. olanzapine 2.5mg,
patient’s symptom severity has improved on the
medication, patient is able to sleep well on the
medication. No side-effects reported to the
medication
FAMILY HISTORY
Patient is first born of a non consangious marriage
Father is working as a farmer patient’s mother is a
housewife patient has a younger brother who’s
aged eight years studying in 3rd standard
History of tobacco consumption in the father
around one packet per day
Patient maintains good interpersonal relationship
with her family members acc to the father
The father reports that the patient is very
obedient to the parents.
On asking about differences in parenting shown to
both the chidren, the father denies of any
favouritism of the parents towards their children
When asked about the patient’s relationship with
her family members patient held a heart sign to
her father and said that she loved him, when
asked about her mother she said that she loved
her too.
No h/o Psychiatric illness in family members or
relatives.
PERSONAL HISTORY
Birth history full term normal delivery, uneventful
childhood history no history of frequent illness no
history of behavioural abnormalities
Schooling
patients started school at the age of five years
patient is currently studying in nine standard and
according to her father patient does not lag in her
studies and scores an average of 70 out of 100 in
most of her subjects
Menstrual history patient attain minority at the
age of 12 years patient has irregular menses
wherein she has every two to three months
LMP was three months ago
Sexual history- patient not forthcoming with any
information
- no history indicating any child sexual abuse
TEMPERAMENT
1.ACTIVITY level- moderate, could sit still
2. Adaptability- moderately difficult to adapt
3. Rhythmicity – predictable rthym involving
sleep,food and bowel movements
4.Approach withdrawal – With the introduction
of new events the patient would take time to
get adjusted to the new scenario
5.Threshold level: moderate (w.r.t
noise,heat/cold, taste)
6.Intensity of reaction- moderate reaction to
not liking something
7.Quality of mood- happy
8.Distractibility - low
9.Persistence and attention span – continued till
she achieved the goal
Inference- slow to warm up baby

GENERAL PHYSICAL EXAMINATION

General Observation : Patient appeared

fearful during the interview and would easily
become restless to questions put forward to
her and would start telling that she is
becoming anxious, she had to be repeatedly
reassured to continue with the interview,
several times she had to be given stern
warning on to answer the questions, she
would start to collect saliva and had to be
repeatedly told to swallow it.
Patient is moderately built and nourished,
dressed appropriately
Weight – 40kg
Height- 142cm
Bmi = 20.6
No pickle
Systemic examination
CVS- S1,S2 +, NO MURMUR
RS- NVBS, NO CREPTS
P/A- SOFT, NON-TENDER, NO
ORGANOMEGALY
CNS- no neurocutaneous markers
Normal cranial nerves
normal reflexes
no cerebeller signs

ON MSE- Conscious cooperative oriented to

time-
night place Bhims Hospital
person father and dr
Eye to eye established with difficulty
Fleeting Rapport
Stereotypical gestures of hands with
collection of saliva in the mouth
Speech- increased rate/ tone and n.volume
Decreased reactivity time increased procedure
spontaneous coherent
Speech sample – when asked about Deepavali
patient responded nam maneli deepa hach
thrae, naanu deepa hach thini, nandu thangee
idhe, avalu nan math kelthilaa, deshnur alli
nam mane idhe, naan doctor agthini
When asked her name- nan hesuru helthini ,
adhrae neevu nange byebaaruthdu badi
baaruthu nan hesuru soni illa nan hesuru
Kavitha ( on being asked to tell her correct
name) nan hesuru Anjali suresh
Mood- patient replied I am anxious
Affect- labile range and reactivity, inapprpriate
congruent to thought
Thought- Form- derailment
Stream- flight of ideas
Perception- nad
Cognitive functions
1.Attention and concentration
Forward up to
Backward Up to 5
Subtraction 21 could do in 20 seconds
Attention aroused and concentration
sustained
2.Memory
Immediate intact
Recent -could tell her address
Remote – could tell her dob and siblings dob
3.Intelligence- could name the pm and name
5 rivers – average
4.Comprehension- rain-umbrella
If cold- sit under fire- intact
5.Arithmetic – able to do addition and
subtraction
Can recite upto 7 tables
Can do simple single digit multiplication and
division.
6.Abstraction-
differences stone( it’s a stone) potato (to eat)
 TV (TO SEE) Radio ( to listen to songs)
Similarities- orange and banan- fruits
Table and chair- its in school
Proverb – could not decipher the exact
meaning
Concrete

7.Judgement-
Personal – I will study and take care of my
family
Social- historically impaired
Test – fire I will inform parents
8.Insight- grade 1

Diagnostic Formulation-
13 year old female patient hailing from
Deshner studying in nine standard with total
duration of illness 45 days, Insidious in
onset progressive and episodic in course
presenting with complaints of talking to self
from 45 days abnormal behaviour from 45
days, no Precipitating factor could be
elicited. Patient was previously treated in
paediatrics department and diagnosed as
dissociative disorder patients started on
tablet olanzapine 2.5 mg once in the night
from the past ten days, history of irregular
menses from menarche, Slow to warm up
temperament. On MSE Stereotypical Act of
collecting saliva in the mouth which had to
be reminded to be swallowed, Fleeting
rapper with the doctor as the patient would
often become agitated saying that she is
feeling anxious, increased volume and tone
of speech with increased prosody patient
would often talk like a toddler and would
immediately change her voice and talk like a
grown up woman and sometimes would
even talk like an elder woman, Patient
reported that she was not at peace with
labile affect with derailment of thought and
flight of ideas, concrete abstractability with
grade one insight

PROVISIONAL DIAGNOSIS
1.Dissociative disorder F44
- SYMPTOMS under control of the patient
 - Symptoms increasing in intensity infront
of others
- When reprimanded or scolded patient
stops her symptom presentation
abruptly
2.Unspecified non-organic Psychosis
- Continuous course, patient not reaching
pre-morbid levels even when symptoms
are controlled
- On MSE- labile affect with derailment of
thought process and flight of ideas,
concrete abstractibility with impaired
social judgement and grade 1 insight
3.BPAD IN MANIA WITH PSYCHOTIC
SYMPTOMS
- Patient presented with abnormal
behaviour with increased hand
gesturing and restlessness lasting for 15
days after which on discgarge from
hospital patient started to be socially
witdrawn from her family members
- On MSE increased rate and tone of
speech with decreased reactivity time
 and flight of ideas noticed in the speech
sample
I would like to admit the patient to clarify the
diagnosis and rule out physical illness
Plan for routine investigations
- Hb- anemia
- Tlc- to rule out infection
- Serum electrolytes- to rule out acid-
base disturbances
- LFT-RFT- TO rule out systemic DISEASES
- CT Brain- to rule out organic diseases
- EEG – to rule out underlying seizure
disorders

AS no stressor could be elicted, I will

discuss with my consultants for need of
narcoanalysis to elicit stressor

Pharmacological mamagement
Increase olanz to 5mg
Add fluoxetine (ssri)
Non- pharmacological
- Psychotherapy
- CBT
- Hypnosis
Course in the hospital so far
Patient when asked anything starts
behaving like an irritated toddler
beginning to cry and has to be warned
to behave properly, in the presence of
many staff patient begins to increase
intensity of symptoms.
Patient is eating well and sleeping well.