Conversion / Dissociative Disorders

Question 1

What is conversion disorder?

Answer 1

A condition where emotional or mental distress can result in the manifestation of physical symptoms (in the absence of a physical disorder to explain them).

Patient has no control over physical response.

The sx seen are incompatible with any condition.

Typically involves loss of motor or sensory function

Question 2

What is a dissociative disorder?

Answer 2

A group of psychiatric conditions characterized by disruptions in memory, awareness, identity, or perception.

The clinical features of dissociative disorders are diverse and can present across various domains, including cognitive, emotional, behavioural, and somatic manifestations.

Question 3

Describe acute and chronic conversion disorder

Answer 3

• Acute – tend to remit after a few weeks/months, esp. if onset associated with a traumatic life event
• Chronic (i.e. paralyses) – if onset associated with chronic problems or interpersonal difficulties

Question 4

What are the ICD-10 subtypes of dissociative disorder?

Answer 4

• Dissociative Amnesia = loss of memory (too great to be explained by ordinary forgetfulness)
• Dissociative Fugue = dissociative amnesia + purposeful travel beyond normal everyday range
• Dissociative Stupor = lack of voluntary movement / normal responses to external stimuli (light, noise, touch), + evidence of stress from recent event
• Trance & Possession Disorders = temporary loss of personal identity and full sense of awareness of surroundings
• Dissociative Motor Disorders = loss of ability to move whole/part of a limb/s - close resemblance to ataxia, apraxia, akinesia, aphonia, dysarthria, dyskinesia, seizures…
• Dissociative Convulsions = mimic epileptic seizures (however, tongue-biting, bruising from falls and incontinence rare), consciousness maintained or replaced by a state of stupor or trance
• Dissociative Anaesthesia = areas of anaesthesia do not follow normal dermatomal distribution - may be accompanied by paraesthesia

Question 5

Describe dissociative vs somatisation disorder

Answer 5

Dissociative = disorders of physical functions under voluntary control and loss of sensation

Somatisation = disorders involving pain or autonomically-controlled sensations

Question 6

What is the aetiology of dissociative disorder?

Answer 6

• Extreme trauma
• Extreme stress
• Depression
• Disturbed relationships

Theories suggest that symptoms are caused by the repression of unconscious intrapsychic conflict and the conversion of the resulting anxiety into a physical symptom. This results in the relief of emotional conflict (primary gain) and the advantages of assuming the sick role.

Question 7

What are the S/S of dissociative disorder?

Answer 7

Vary from person to person & in severity
May occur just once or repeat due to a reminder of the stressor

Onset
Acute, specific, dramatic, following sudden stress / conflict

Presentation:

• Tremor
• Balance issues
• Paralysis / numbness / weakness in limbs
• Temporary blindness / blurred vision
• Aphonia (cannot speak) / slurred speech
• Partial / complete hearing loss
• Difficulty swallowing
• Seizures
• Psychogenic amnesia (loss of all memories, including own identity)
• Multiple personalities
• Fugue (loss of memory entirely and wander away from home)
• Stupor
• May show a relative lack of concern despite showing worrying symptoms (i.e. seizures)

Question 8

What are the investigations for dissociative disorder?

Answer 8

Exclude organic cause

• Raised prolactin after a real seizure / normal prolactin after a dissociative convulsion

Question 9

What is the DSM-V criteria for a diagnosis of conversion disorder?

Answer 9

1. Sensory sx of bodily movements that cannot be controlled
2. Sx that cannot be explained mentally or physically
3. Sx that occur after trauma / stress
4. Sx that negatively affect daily life

Question 10

What is the management for dissociative disorder?

Answer 10

Self-limiting spontaneous recovery
75% return to normal

Supportive therapy:

• Encourage return to normal activity
• Healthy work-life balance
• Healthy eating and exercise
• Avoid reinforcing behaviour (i.e. providing a wheelchair for dissociative stupor/motor disorders)
• Address physical stressors rather than focus on physical manifestations

Psychotherapy and CBT/DBT

Identify and treat any co-morbid depression

Question 11

What is Hoover’s sign?

Answer 11

A quick and useful clinical tool to differentiate organic from non-organic leg paresis

• Non-organic paresis = pressure is felt under the paretic leg when lifting the non-paretic leg against pressure (due to involuntary contralateral hip extension)