Dissociative [Conversion] Disorders

By | February 5, 2015

Description of Medical Condition

A sudden change in state of consciousness, identity, motor behavior, thoughts, feelings and perception of external reality to such an extent that these functions do not operate congruently. Many pathologic symptoms can be found, but the patient experiences dysphoria, suffering, and maladaptive functioning. Disorders include:

• Dissociative amnesia

• Dissociative fugue

• Dissociative identity disorder

• Depersonalization disorder

• Dissociative disorder not otherwise specified (NOS). Authors may include somnambulism (sleep-walking disorder), conversion reactions, pseudo-epilepsy and (in some cultures) a variety of possession syndromes.

System(s) affected: Nervous

Genetics: N/A

Incidence/Prevalence in USA: Transient symptoms of depersonalization/derealization in the general population are common with a lifetime prevalence rate of 26-74% with 31-66% occurring at the time of a traumatic event. 8-10% of the general psychiatrically ill. As many as 70% of young adults report short periods of dissociative experiences that are self-limiting and resolve spontaneously.

Predominant age: Adolescents and young to middle age adults; rare as a new illness in elderly. If untreated, may linger from childhood into adult and old age.

Predominant sex: Female > Male (2:1)

Medical Symptoms and Signs of Disease

All disorders share:

• Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning

• Symptoms are not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy)

• Dissociative amnesia:

– One or more episodes of inability to recall important personal information that is too extensive to be explained by ordinary forgetf ulness

– Not occurring during another psychiatric illness and not due to effects of chemical substance (drug abuse or medication)

– Not due to a neurological or other medical condition (e.g., head trauma)

• Dissociative fugue:

– Sudden unexpected travel away from home or one’s customary place of work with an inability to recall one’s past

– Confusion about personal identity or assumption of a new identity (partial or complete)

– Above symptoms do not occur exclusively during course of dissociative identity disorder

– Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning with activities of daily living

• Dissociative identity disorder:

– Presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about environment and self).

– At least two of these identities or personality states recurrently take control of the person’s behavior

– Inability to recall important personal information (too extensive to be explained by ordinary forgetfulness)

– Reports of time distortion, lapses and discontinuities

– Experiencing voices from inside one’s head

– Chronic headaches

– History of severe emotional or physical abuse as a child

– Referring to self as “he/she,” “we,” “us”

Eating disorders

– Flashbacks

– Feelings of derealization

– Feelings of depersonalization

– Amnesia about important childhood events

– Personal objects and belongings that cannot be accounted for

– Disowning unrecalled behaviors

– Different handwriting styles

– Different signatures and names found in personal diary

– Sudden mood changes

– Sudden behavioral changes, i.e., from adult to young child

– Episodes of deja vu

– Feeling controlled by “another person” from within

– Self-inflicted violence such as wrist cutting

• Depersonalization disorder:

– Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of one’s mental processes or body (e.g., feeling like one is in a dream)

– During the depersonalization experience, reality testing remains intact

– The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder or another dissociative disorder

• Dissociative disorder NOS: Predominant feature is a dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific dissociative disorder. Examples:

– Clinical presentations similar to dissociative identity disorder that fail to meet the full criteria for this disorder. Examples include a) there are not two or more distinct personality states or b) amnesia for important personal information does not occur

– Derealization unaccompanied by depersonalization in adults

– States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought reform, or indoctrination while captive)

– Dissociative trance disorder: Single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one’s control.

– Possession trance: Involves replacement of the customary sense of personality identity, attributed to the influence of a spirit, power, and associated with stereotyped “involuntary” movements or amnesia.

– Loss of consciousness, stupor, or coma not attributed to a general medical condition

– Ganser syndrome: The giving of approximate answers to questions (e.g., “2 plus 2 equals 5”) when not associated with dissociative amnesia or dissociative fugue

What Causes Disease?

• Physical, emotional, verbal, or sexual abuse in childhood

• Sudden and severe trauma or threat to one’s psychological or physical integrity

• Sudden and unexpected exposure to watching others being killed or severely injured (as in an industrial or car accident)

• A preponderance of coping with trauma and internal or inter-personal conflicts by the use of dissociation

• Psychological/social support to cope with the trauma/ abuse was not available

Risk Factors

• Exposure to neglect, abuse and trauma in one’s childhood

• Tendency to cope with life stresses by excessively using an escape mechanism of day dreaming and/or dissociation

Diagnosis of Disease

Differential Diagnosis

• Other mental/CNS disorder: Schizophrenia, depression, anxiety disorder, mania, obsessive/compulsive disorder, identity disorder, phobic disorders, eating disorders

• Other: Extreme sensory deprivation, epilepsy; early phases of dementia, encephalitis, head trauma, migraine, cerebral vascular disease, brain tumors

• Endocrinopathy: Hypoglycemia, hypothyroidism hyperthyroidism

• Miscellaneous: Huntington disease, carbon monoxide poisoning, mescaline intoxication, botulism, hyperventilation

• Obstructive sleep apnea, nocturnal myoclonus

Laboratory

Toxicology screening may be helpful

Drugs that may alter lab results: Lithium carbonate may produce hypothyroidism

Disorders that may alter lab results:

Patients (especially those with dissociative identity disorder) may present with medical oddities such as fast healing of broken bones, radiographs resembling brain atrophy, brain infarcts, lupus, or abnormal pulmonary function tests.

A variety of symptoms (including blurred vision, nausea and vomiting, rapid heart beat, palpitation, extreme bradycardia, urinary frequency and urgency, extreme changes in levels of blood glucose) may lead to erroneous diagnosis.

Pathological Findings

N/A

Special Tests

EEG to rule out epilepsy and sleep disorders. Polysomnogram to rule out sleep apnea.

Imaging

CT scan and MRI of the head to rule out multiple infarct dementia, brain tumors, and some forms of encephalopathy

Diagnostic Procedures

• Neuro-psychological testing is helpful in ruling out learning disabilities and cognitive deficits due to early dementia or borderline mental retardation

• Psychological testing helps identify specific psychiatric disorders, personality structure and dynamics

• Dissociation scales help assess the tendency to dissociate in daily living activities

Amobarbital (Amytal) interviews (narcoanalysis) and special interviews under hypnosis are useful in selected cases

• Clinician reviews patient’s diary for handwriting and signature changes.

Treatment (Medical Therapy)

Appropriate Health Care

• Outpatient, individual psychotherapy

• At times of crisis: intensive hospital-based treatment (as a protection for patients with suicidal or homicidal impulses, and/or self-inflicted violence)

• Use inpatient care to verify diagnosis with special tests and begin treatment program that continues on outpatient basis

• Note: Treatment emphasis on progress in the adaptive functions with daily living activities, symptom alleviation, ego strengthening, prevent regressions

General Measures

• Individual psychotherapy plus behavior modification, narcoanalysis and narcosynthesis, hypnoanalysis and hypnotherapy

• Adjuncts: support groups, group therapy, expressive art therapy, occupational and recreational therapy

• Bibliotherapy and grapho-therapy are useful

Activity

Based on patient’s condition

Patient Education

• Self-hypnosis, relaxation exercises and guided imagery

• Encourage patients to read about their condition and be inspired by others who have been diagnosed, treated, and recovered, e.g., “A Mind of My Own” by Chris Sizemore, published by W. Morrow, New York, 1989

Medications (Drugs, Medicines)

Drug(s) of Choice

• No medications are specifically curative. The following have been helpful:

Antidepressants: depression

– Benzodiazepines: anxiety and insomnia

Propranolol 80-400 mg/day: flashbacks and other dissociative symptoms

– Neuroleptics (in low doses): self-abusive behavior. Haloperidol 2-5 mg/day; perphenazine 4-16 mg/day; risperidone 1-4 mg/day

– Severe agitation, droperidol 1-5 mg IM (effective in producing calm sleep/stopping agitation)

– Mood swings, in dissociative disorders, do not respond to the use of lithium carbonate, carbamazepine or valproic acid unless patient has co-morbid bipolar disorder

Contraindications: N/A

Precautions:

• Short-acting benzodiazepines abuse potential

• Overdose/suicide potential with TCAs

• Very low doses of neuroleptics can be used without producing tardive dyskinesia (try to avoid higher doses)

• Risperidone may be associated with hyperglycemia and ketoacidosis

Significant possible interactions: Avoid MAO inhibitors with TCAs or SSRIs

Alternative Drugs

• Anxiety symptoms

Buspirone (Buspar) 30-80 mg/day for anxiety

• Obsessive-compulsive symptoms

Clomipramine (Anafranil) 75-200 mg/day

Fluvoxamine (Luvox) 100-300 mg/day

Fluoxetine (Prozac) 20-80 mg/day

Paroxetine (Paxil) 20-60 mg/day

Sertraline (Zoloft) 50-200 mg/day

• Alternative neuroleptics have recently been found useful for the control of self-inflicted violence

– Risperidone (Risperdal) 0.5-4 mg/day

Olanzapine (Zyprexa) 2.5-10 mg/day

Quetiapine (Seroquel) 25-200 mg/day

Aripiprazole (Abilify) 5-15 mg/day

Ziprasidone (Geodon) 40-100 mg/day

Patient Monitoring

• Outpatients: 1-4 hrs of psychotherapy per week to avoid hospitalization

• Inpatients: more intensive treatment, e.g. daily psychotherapy

Prevention / Avoidance

• Child abuse prevention via parent education and community agency intervention

• Crisis intervention following individual trauma or disasters for prevention of chronic morbidity/disability

Possible Complications

Self-inflicted violence; suicide attempts; substance abuse and chemical dependency

Expected Course / Prognosis

Ranges from spontaneous improvement, in cases of dissociative amnesia, dissociative fugue, and depersonalization disorder, to acute and chronic morbidity in others

• Without treatment, dissociative identity disorder patient may have a healthy functioning facade, with episodes of depression, confusion, mood swings, etc. With age. intensity/frequency of dissociative experiences may decrease and crystallize around 1 -2 major personality states.

• Effective treatment produces partial or full recovery for many patients

Miscellaneous

Associated Conditions

See Causes

Age-Related Factors

Pediatric: Suspect abuse or neglect

Geriatric: Decrease in dissociative disorders. Medication side effects more likely.

Pregnancy

N/A

Synonyms

• Hysterical neurosis, dissociative type

• Ganser syndrome

International Classification of Diseases

300.15 Dissociative disorder or reaction, unspecified

301.50 Histrionic personality disorder, unspecified