3. ANALISIS ELECTORAL
3.4 ELECCION 2007
These disorders are characterised by the follo wing clinical features:
1. Disturbance in the normally integrated func tions of consciousness, identity and/or memory.
2. Onset is usually sudden and the distur bance is usually temporary. Recovery is often abrupt.
3. Often, there is a precipitating stress before the onset. There is a clear temporal relation ship between the stressor and the onset of the illness.
A frequent stressful situation is an ongoing war.
4. A ‘ secondary gain’ resulting from the develop ment of symptoms may be found.
5. Detailed physical examination and investi ga tions do not reveal any abnormality that can explain the symptoms adequately.
The common clinical types are described below:
Dissociative Amnesia
This is the commonest clinical type of dis socia tive disorder. Occurring mostly in adolescent and young adults (females more than males, except in war), it is characterised by a sudden inability to recall important personal informa tion (amnesia), particularly concern-ing stress ful or trau matic life events. The amnesia can not be explained by everyday forgetfulness and there is no evidence of an underlying medical illness.
Most often, dissociative amnesia follows a trau-matic or stressful life situation. Sometimes, imagined stressors or expression of ‘forbidden’ impulses may also precipitate the onset of amnesia.
This amnesia is of four types (Table 8.5). During the amnesic period, there may be slight clouding of con-sciousness. In the post-amnesic period, the awareness of disturbance of memory is present.
Dissociative Fugue
Dissociative fugue is characterised by episodes of wandering away (usually away from home). During the episode, the person usually adopts a new identity with complete amnesia for the earlier life. The onset is usually sudden, often in the presence of severe stress. The termination too is abrupt and is followed by amnesia for the episode, but with recovery of memories of earlier life. The characteristic feature is the assumption of a purposeful new identity, with absence of awareness of amnesia.
Table 8.4: Dissociative Convulsions and Epileptic Seizures
Clinical Features Epileptic Seizures Dissociative Convulsions (Hysterical Fits)
1. Attack pattern Stereotyped, known clinical patterns Absence of any established clinical pattern. Purposive body movements occur
2. Place of occurrence Anywhere Usually indoors or at safe places 3. Warning Both prodrome and aura are stereotyped Variable
4. Time of day Anytime. Can occur during sleep Never occur during sleep
5. Tongue bite Usually present Usually absent. Cheek and lip bite may be present
6. Incontinence of urine
and faeces Can occur Very rare
7. Injury Can occur Very rare. If occurs, it is minor or
may be accidental
8. Speech No verbalisation during the seizure Verbalisation may occur during the fi t
9. Duration Usually about 30-70 sec. (Short) 20-800 sec. (Prolonged)
10. Head turning Unilateral Side to side turning
11. Eye gaze Staring, if eyes are open Avoidant gaze
12. Amnesia Complete Partial
13. Neurological signs Present, e.g. up-going plantars Absent
14. Post-ictal confusion Present Absent
15. Stress Present in 25% Present much more often
16. EEG - Inter-ictal
- Ictal Usually abnormal;
Abnormal Usually normal
Normal 17. Serum prolactin Increased in post-ictal period (15-20 minutes
after seizure; returns back to normal in 1 hour)
Usually normal
Table 8.5: Types of Dissociative Amnesia 1. Circumscribed amnesia (commonest type): There is
an inability to recall all the personal events during a circumscribed period of time, usually corresponding with the presence of the stressor.
2. Selective amnesia (less common): This is similar to circumscribed amnesia but there is an inability to recall only some selective personal events during that period while some other events during the same period may be recalled.
3. Continuous amnesia (rare): In this type, there is an inability to recall all personal events following the stressful event, till the present time.
4. Generalised amnesia (very rare): In this type, there is an inability to recall the personal events of the whole life, in the face of a stressful life event.
An important differential diagnosis is from fugue states seen in complex partial seizures or temporal lobe epilepsy. In complex partial seizures, there is no assumption of a new identity, confusion or disorienta-tion is present during the episode and the episodes are not only linked to any precipitating stress.
Multiple Personality
( Dissociative Identity) Disorder
In this dissociative disorder, the person is dominated by two or more personalities, of which only one is being manifest at a time. These personalities are usually different, at times even opposing. Each per-sonality has a full range of higher mental functions, and performs complex behaviour patterns.
Usually one personality is not aware of the exist-ence of the other(s), i.e. there are amnesic barriers between the personalities. Both the onset and termina-tion of control of the each personality is sudden.
Classical examples in the published literature include ‘Three faces of Eve’ and ‘Sybil’.
Trance and Possession Disorders
Trance and possession disorders ( possession hysteria) are characterised by the control of person’s personality by a ‘spirit’, during the episodes. Usually the person is aware of the existence of the other (i.e. ‘possessor’), unlike in multiple personality. This disorder is very commonly seen in India and certain African countries.
Other Dissociative Disorders
Ganser’s syndrome ( hysterical pseudodementia) is commonly found in prison inmates. The charac teristic feature is vorbeireden, which is also called as ‘ approxi-mate answers’. The answers are wrong but show that the person understands the nature of question asked.
For example; when asked the colour of a red pen, the patient calls it blue.
Aetiology
The aetiological theories of dissociative (and con-ver sion) disorders are predominantly of three types:
Psychodynamic Theory
The explanation given by this theory can be summa-rised in a fl ow diagram (Fig. 8.2). For further details regarding the defense mecha nisms and Freudian theory, see Tables 17.1 and 17.2.
Behavioural Theory
According to this theory, dissociative (and conver sion) symptoms are learned responses in the face of stress.
For the fi rst time, the symptom may be learned from the surrounding environ ment (e.g. seeing a paralysed patient).
The development of the symptom brings about psychological relief by avoidance of stress and is thus secondarily reinforced.
Biological Theory
The biological basis of dissociative (conver sion) disor-ders is far from proven. Some long-term studies (e.g.
Slater) have found that up to 80% of patients, diag-nosed as ‘ hysteria’, were later found to have physical illnesses. However, replications of such studies have not found such high fi gures.
Conversion symptoms are frequently seen in the patients with epilepsy and it may at times be diffi cult to differentiate between true seizures and pseudo-seizures.
Similarly, ‘ conversion-release’ symp toms are seen in some cerebral cortex lesions. However, these are only conversion symptoms and are not dissociative (and conversion) disorders [i.e. other features for diag nosis of dissociative (con version) disorders are not present]. Hence, these are of doubtful help in elucida ting the aetiology of dissociative (and conver-sion) disorders.
Diagnosis
Diagnosis is based not merely on the absence of objec-tive signs of physical illness, although it is very impor-tant to exclude an underlying or associated physical illness. The presence of positive points in history and examination should be present, before a diagnosis of
dis sociative (and conversion) disorders can be made.
These positive points are the characteristic clinical features listed previously.
As dissocia tive (and conversion) disorders and physical illness can be co-existent, a detailed exami-nation is a must. Dissociative (conversion) symptoms appearing for the first time in an elderly male, especially in a male more than 50 years old, a strong sus picion of underlying physical or major psychia tric illness should be kept in mind.
Other clinical features of dissociative (conversion) disorders include la-belle-indifférence, which is a lack of concern towards the symptoms, despite the apparent severity of the disability pro duced. Although earlier thought to be a hallmark of dissociative (conversion) disorders, it is now known to be present even in physical illnesses. In addition, it is not always present in dissociative (con version) disorders.
Premorbid histrionic personality traits are often present, although a personality disorder is less com-monly present.
Treatment
Behaviour Therapy
Since the patients with dissociative disorders can be attention seeking and their symptoms increase with focus of attention, the symptoms should not be un-duly focussed on. These patients should be treated as normal, and not encouraged to stay in a sick-role. Any improvement in sympto matology should be actively encouraged.
Since these patients can also very suggestible, they respond quickly to the above-stated methods, with a consistently fi rm but empathic attitude.
When there is a sudden, acute symptom, its prompt removal may prevent habituation and future disabil-ity. This may be achieved by one of the following methods:
i. Strong suggestion for a return to normalcy.
ii. Aversion therapy (liquor ammonia; aversive electric stimulus; pressure just above eye balls or tragus of ear; closing the nose and mouth) are occasionally employed carefully in resistant cases.
Fig. 8.2: Psychodynamic Theory of Dissociative (Conversion) Disorder
However, the use of aversion therapy has been decried as it:
a. tends to get over-used;
b. may harm the patient;
c. violates the basic human rights of the patient;
and
d. can lend a wrong mental pic ture of the patient in the physi cian’s mind, i.e. of a ‘manipulator’
needing punishment!
The current status is that aversion therapy is not a preferred treatment choice.
iii. Amplifi cation of suggestion with hypno sis, free-association, intravenous amytal or thiopentone, or intra venous diazepam.
Psychotherapy with Abreaction
Abreaction is bringing to the conscious aware ness, thoughts, affects and memories for the fi rst time. This may be achieved by:
i. Hypnosis.
ii. Free association.
iii. Intravenous thiopentone or diazepam: The aim of abreaction with IV thiopentone is, both, to make the confl icts conscious and to make the patient more suggestible to therapist’s advice.
Once the confl icts have become conscious and their affects (emotions) have been released, the conversion or dissocia tive symptom disap-pears.
Supportive Psychotherapy
Supportive psychotherapy is needed especially when the confl icts (and the current problems) have become conscious and have to be faced in routine life. It is an important adjunct to treatment.
Psychoanalysis
This mode of treatment is chosen not on the basis of conversion/dissociative symptoms but on the total personality structure of the patient. Several patients respond remarkably well. The total length of therapy in classical psycho analysis is usually fi ve years or more.
Drug Therapy
Drug treatment has a very limited role in disso ciative (and conversion) disorders (apart from the use of IV thiopentone, amytal or diazepam in abreaction). A few patients have disabling anxiety (although anxiety as a rule is rather uncommon in ‘hysteria’) and may need short-term benzodiazepines.