1. MANAGEMENT OF
DISSOCIATIVE DISORDERS
FAREED MINHAS
Professor of Psychiatry
HEAD, Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi

2. NEUROTIC, STRESS RELATED
AND
SOMATOFORM DISORDERS
FAREED MINHAS
Professor of Psychiatry
HEAD, Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi

3. INTRODUCTION

Disorders here grouped due to association with
- concept of neurosis
- psychological causation

NEUROSIS : when the person experiencing the
symptoms of mental disorder retains insight into his
condition ( in touch with reality)

This block in ICD-10 includes : anxiety disorders,
obsessive-compulsive disorders, dissociative disorders,
somatoform disorders and reactions to severe stress/
adjustment disorders

4. PERCENTAGE OF MAJOR DIAGNOSTIC
CATEGORIES DURING FOUR YEARS IN IOP
Journal of CPSP (2001)
Fig.3 Percentage of major diagnostic categories.
overall%
Males
Females
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Scizophr Depressi
Bipolar
Mania
Drug
Personal
Depende
ity
OCD
Conversi
enia
on
on
overall%
8.40%
37%
11.40%
4.80%
10.60%
1.50%
1.43%
4.80%
Males
5.70%
18%
4.15%
2.90%
10.60%
0.92%
0.95%
0.60%
Females
2.70%
19%
7.20%
1.90%
0%
0.66%
1.90%
4.20%

5. ANXIETY DISORDERS
• Abnormal states in which the most striking features
are mental and physical symptoms of anxiety not
caused by organic brain disease or other psychiatric
disorder
Generalized
Anxiety Disorder
Phobic Anxiety
Disorder
Unvarying and
persistent
anxiety
Intermittent;
arising in special
circumstances
Panic Disorder
Intermittent but
unrelated to
particular
circumstances

6. Generalized Anxiety Disorders
The symptoms of generalized anxiety disorder include:
 Psychological- Fearful anticipation; irritability; sensitivity
to noise; restlessness, poor concentration, worrying thoughts
Physical- Gastrointestinal: Dry mouth-difficulty in
swallowing-epigastric discomfort
-excessive wind-loose motions
Respiratory:
Constriction in chest-difficulty
inhaling-overbreathing
Cardiovascular: Palpitations-discomfort in
chest-awareness of missed
beats

7. Generalized Anxiety Disorders
(contd.)
Genitourinary: Frequent/Urgent micturition-Failure
of erection-menstrual discomfortamenorrhoea
Neuromuscular: Tremor-prickling sensationstinnitus-dizziness-headache-aching
muscles
 Sleep disturbances- Insomnia; night terrors
 Other symptoms- Depression; obsessions;
depersonalization
Differential Diagnosis : DEPRESSIVE DISORDER
SCHIZOPHRENIA
PRESENILE/SENILE DEMENTIA
PHYSICAL ILLNESS (Thyrotoxicosis
-Pheochromocytoma-Hypoglycemia)

8. Aetiology of GAD
Stressful events
Genetic causes
Personality
Environmental
influences
Treatment
Counseling
Cognitive Behavior
Treatments (anxiety
management
training)
Drug therapy
(benzodiazepines;
tricyclic antidepressants
and beta-blockers)

9. OBSESSIVE-COMPULSIVE
DISORDERS(Contd.)

Differential Diagnosis: GENERALIZED ANXIETY
PANIC DISORDER
PHOBIC DISORDER
DEPRESSIVE DISORDERS
SCHIZOPHRENIA
ORGANIC CEREBRAL DISORDER

Aetiology : Genetics, evidence of brain disorder,
abnormal serotinin levels and environment

Treatment- Counseling; drugs(anxiolytics short-term;
tricyclic antidepressant long-term or an SSRI); behavior
therapy; psychotherapy and psychosurgery

10. Phobic Anxiety Disorders

Same core symptoms as in GAD but they occur in
special circumstances. The patient is free from
anxiety rest of the time. 2 features characteristic
are:
- person avoids these situations
- anticipatory anxiety

Phobic syndromes fall into 3 categories mostly:
- Simple phobia
- Social phobia
- Agoraphobia
Mostly the treatment here is psychological (cognitive
behavior therapy) however drugs (antidepressants and
benzodiazepines) are also added

11. Phobic Anxiety Disorders(contd.)



Simple Phobia – the person is inappropriately anxious in
presence of one or more particular objects or situation.
Eg. Arachnophobia (spider phobia)
acrophobia (phobia of height)
phobia of flying
phobia of illness
Social Phobia – inappropriate anxiety is experienced in
situations in which the person is observed and could be
criticized. Eg. Phobias of excretion
Phobias of vomiting
Agoraphobia – patients are anxious when they are away
from home, in crowds and situations they can’t leave easily
from.

12. Panic Disorder

Panic disorder is episodic paroxysmal anxiety
characterised by recurrent attacks of severe anxiety
which are not related to any situation and
unpredictable

Symptoms of a ‘panic attack’ :
-
Shortness of breath and smothering sensations
Choking
Palpitations and accelerated heart rate
Chest discomfort or pain
Sweating
Dizziness, unsteady feelings or faintness
Nausea or abdominal distress

13. Panic Disorder(contd.)

Depersonalization or derealization
Numbness or tingling sensations
Flushes or chills
Trembling or shaking
Fear of dying
Fears of going crazy or doing something uncontrolled
The aetiology is based on 3 hypothesis:
- Biochemical (endogenous anxiety)
- Hyperventilation
- Cognitive hypothesis

-
Treatment
- Benzodiazepines and antidepressants (TCAs/SSRIs)
- Rebreathing into a shopping bag

14. OBSESSIVE-COMPULSIVE
DISORDERS

Characterized by obsessional thinking, compulsive
behavior, varying degrees of anxiety, depression and
depersonalization

Main features maybe:
-
Obsessional
Obsessional
Obsessional
Obsessional
Obsessional
Obsessional
thoughts/images
ruminations/doubts
impulses
rituals
phobias
slowness

15. DISSOCIATIVE DISORDERS

Dissociative [conversion] disorders involve partial or
complete loss of the normal integration between the
memories of the past, awareness of identity and
immediate sensations, and control of bodily movements

Level of consciousness about the episode may vary and
is difficult to assess

Several forms of dissociation are seen:
Dissociative amnesia: sudden loss of memory [usually
short-term] which is not due to concurrent organic
disease such as epilepsy, multiple schlerosis


16. DISSOCIATIVE DISORDERS(Contd.)

Dissociative pseudodementia: disorder with extensive
abnormalities of memory and behavior that suggest
generalized intellectual impairment. Simple tests are
answered wrong though in a way strongly suggesting that
the correct answer is in the patient’s mind

Dissociative fugue: is a state of amnesia alongwith a
purposeful journey to a place out of daily range during
which self-care and basic interaction is maintained

Dissociative stupor: the patient is motionless, mute and not
responsive to stimulation in the absence of any physical or
psychiatric finding and presence of a recent stress factor

17. DISSOCIATIVE DISORDERS(Contd.)

Trance and possession disorders : there is temporary loss
of both personal identity and full awareness of
surroundings. Focus of attention is narrowed to few
aspects of environment. The person repeats movements,
adopts postures or repeats utterances

Dissociative identity disorder : multiple personality
disorder where the person switches between two
personalities without being aware of it

Ganser’s Syndrome : presence of ‘approximate answers’ to
questions for intellectual functioning; psychogenic physical
symptoms; hallucinations and clouding of consciousness

18. DISSOCIATIVE DISORDERS(Contd.)

Dissociative disorders of movement and sensation : there is
a degree of physical disability and loss of usually cutaneous
sensations against all physical evidence

Dissociative motor disorders : loss of ability to move part
or whole of the limb or exaggerated shaking/trembling of
one or more extremities or whole body

Dissociative convulsions : pseudoseizures. They resemble
epileptic fits but tongue-bite, fall and urinary incontinence
are rare[almost absent]

Dissociative anaesthesia or sensory loss

19. Follow up studies
Slator(1965)National Hospital for Nervous disease.
85 patients followed up for 9 years






60 % Organic disease
17 % had serious psychiatric disease
13 % had lasting personality disorder
10% had acute psychogenic reaction
The diagnosis of hysteria as a
dangerous myth.
“Not only a delusion but also a snare”

20. The survival of hysteria, A. Lewis(1975) 98
patients suffering from Hysteria, Maudsley hospital, 7-12 years





26 - diagnosis was retained
54 - well and working
11 - other psychiatric disorders
7 - died, one by suicide
“a though old word like hysteria, dies very
hard. It tends to outlive its obituarists”

21. Faith Healers diagnosis





Saya
Jinn possession
Churail possession
Tawiz
Dar





Spirit infestation
Evil eye
Amal
Jhalla / Jhally
Jadoo

22. Etiology



Psychoanalytic terms- primarily a
defense mechanism, withdrawal from a
painful stimuli
Premorbid personality and Mood
disorders
Stressors and Psychosocial factorsmarital, financial, occupational, warrelated stressors

23. DISSOCIATIVE DISORDERS(Contd.)

The treatment is focused on elimination of factors
reinforcing the symptoms and encouragement of
normal behavior.

Other ways of treatment resorted to:
- abreaction
- dynamic psychotherapy

DEPERSONALIZATION DISORDER is a separate
class characterised by an unpleasant state of
perception in which external objects or parts of body
are experienced as unreal/remote/automized.

24. THANK YOU
References: - OXFORD TEXTBOOK OF
PSYCHIATRY(Third Edition)
- ICD-10 (Clinical and
Diagnostic Guidelines)