Dissociative disorders:

Dissociative disorders is a partial or

complete loss of the normal integration
between memories of the past, awareness
of identity and immediate sensations and
control of bodily movements.
Characteristics:
• A clear temporal relationship between the
onset of a psychosocial stress or and the
development of symptoms.
• Sudden onset of symptoms.
• Symptoms are not intentionally produced
• There is usually secondary gain.
• Detailed physical exam and investigations do
not reveal any abnormality
• Labelle indifference.
Epidemiology:
* 1% of population
* Females > male
* More in developing & underdeveloped countries.
* More in uneducated and low socio-economic group

Dissociative disorders can affect

Higher mental functions
Motor system or
Sensory system
 It is important to remember that symptoms
can not be explained by any neurological
illness.

Higher mental functions

Amnesia
Fugue
Multiple personality
Trance & possession state.
Dissociative Amnesia:
Patient suddenly loses memory of certain
traumatic events.

Dissociative Fugue:
Patient wanders away from home and
takes up new identity. He completely
forgets who he was and what he was
doing.
Multiple personality:
Patient keeps on alternating between two
or more personalities of which only one is
being manifest at one time.

Trance and possession disorders:

Person says that he has been possessed
by a spirit or devi.
Dissociative Stupor:
Patient becomes immobile, does not
respond to external stimuli. Speech and
spontaneous purposeful movements are
completely lost. However breathing,
muscle tone, eye movements are not
affected. Patient is neither unconscious or
asleep.
Dissociative motor disorders:
(a) Paralysis: Monoplegia, paraplegia or quadriplegia,
Patient’s weakness changes,
when he is being examined
reflexes are normal,
planters

(b) Abnormal movements: can be tremor, chorea.

These movements either occur or when attention is
directed towards them and may disappear when
patient is unobserved.

These movements do not fit typical clinical picture.

(c) Dissociative Convulsion
C/F Epileptic seizure Dissociative convulsion
1. Attack pattern Stereotyped, known Absence of any established
clinical pattern clinical pattern, purposive body
movements occur
2. Place of occurrence Anywhere Usually indoor or safe places
3. Loss of Complete loss of Partly impaired
consciousness consciousness
4. Duration 3-5 mins Longer duration
5. Time of day Any time Never occur on sleep
6. Incontinence of urine Can occur Very rare
and focus
7. Serious injury or Can occur Very rare
tongue bite
8. Head turning Unilateral Side to side

9. Eye gauze Staring if eyes are Resist eye opening

open
Pupillary reaction to Absent +ve
light
Covneal reflex Abesent +ve
Amnesia Complete Often partial
Planters

Postictal Confusion + -ve

(d) Gait:
Wide based, staggering
Jerky, dramatic,
exaggerated when observal
Dissociative Sensory disturbances
Anaesthesia - Glove and stocking
Hemianaesthesia
Blindness – Unilateral or bilateral
Deafness - rare
 STRESS RELATED DISORDERS

In these disorders , symptoms arise always

as a direct consequence of the severe
acute stress or continued trauma. These
disorders are regarded as maladaptive
responses to severe or continued stress
that interfere with successful coping
mechanisms and thus lead to problems in
social functioning.
1. Acute stress Reaction
Immediate and clear temporal
relationship between an exceptional
stressor and onset of symptoms.
Stressors like death of a loved one,
natural catastrophe, accident, rape etc.
More likely to occur in presence of
physical exhaustion and in extreme of
age. More in females and people with
poor coping skills.
Symptoms range from “dazed” condition,
narrowing of attention, inability to
comprehend stimuli and disorientation.
This state may be followed either by
further withdrawal from the surrounding (to
the extent of dissociative stupor) or by
agitation or over activity.

Autonomic signs of panic anxiety

(tachycardia, sweating, flushing) are
commonly present.
 The symptoms usually appear within
minutes of the impact of stressful stimulus
or event and disappear within 2-3 days
(often within hours) Partial or complete
amnesia for the episode may be present.

Treatment:
Removal of the patient from stressful
environment.
Benzodiazepines in case of agitation.
2. Adjustment disorders:
States of subjective distress and
emotional disturbance usually interfering
with social functioning and performance
and arising in the period of adaptation to a
significant life change or to the
consequences of a stressful life event.
Symptoms: include:-
Depression, anxiety, or mixture of
anxiety and depression, a feeling of
inability to cope, predominate disturbance
of conduct.

Onset is usually within 1 month of the

occurrence of stressful event or life
change and the duration of symptoms
does not usually exceeds 6 months.
Treatment:
Supportive psychotherapy
Coping skill training
Drug treatment may be needed for the
anxiety (benzodiazepines) and for
depression (anti depressant)
3. Post traumatic stress disorders (PTSD)
This arises as a delayed response to a
stressful event or situation of exceptionally
catastrophic or threatening nature (natural or man
made disaster, combat, serious accident,
witnessing violent death of other or being the
victim of torture, terrorism, rape or other crime)

Clinical features:
Typical symptoms
• Recurrent or intrusive re-experiencing of the
traumatic event either in memory flashbacks or
dream.
• Intense distress at exposure to events that
resemble the original event.
• Effort are made to avoid thoughts and
feelings associated with the trauma.
• Partial or complete amnesia for the event.
• Feeling of numbness and detachment from
other people and unresponsiveness to
surroundings.
• Anhedonia
• Increased arousal, hyper vigilance and
enhanced startle reaction.
• Anxiety and depression are commonly
associated with above symptoms and signs.
• There may be insomnia.

Onset follows the trauma with a latency period

which may range from a few weeks to six
months.

Course and Prognosis:

Majority of PTSD patients show complete
recovery. Few may show chronic course.
Management:
* Pre disaster management
* Post disaster management
* Psychotherapy
* Pharmacotherapy
 SOMATOFORM DISORDERS
Physical symptoms without organic basis. Physical
symptom suggest physical illness (hence somatoform)
for which no demonstrable organic findings.

Somatoform disorders are divided into:-

1) Somatisation disorder:
a) Multiple somatic symptoms involving more
than two systems.
b) Long duration > 2 yrs
c) Symptoms can not be explained medically
2) Hypochondrial disorder:
Conviction of a disease in the absence of it.
 Somatoforin Hypochondriacal
disorders Disorder
• The emphasis is on the • The emphasis is on
individual symptoms. underlying disease.
• Symptoms are • Restricted to one or
changing two systems.
• Patient demands • Wants investigations to
treatment and removal settle diagnosis.
of symptom
• Excessive drug use. • Fear drugs and their
sick effect.
3) Somatoform autonomic dysfunction: Symptoms
refer to organ systems directly under autonomic
control.

Cardiovascular
palpitation.
G.I.T. a) Upper
Aerophagy
Hiccups
b) Lower
flatulence
Irritable bowl
Respiratory System
Hyperventilation
Genitourinary system
Dysuria
4) Persistent pain disorder:

Preoccupation with persistent, severe and

distressing pain in the absence of physical
findings to account for the pain. Clear
psychogenic factors should be present.
 PERSONALITY DISORDERS
Personality is defined as a deeply ingrained
pattern of behavior relating to thinking about
oneself and the surrounding behaviour.
Personality traits are normal, prominent
aspects of personality e.g. shy, social,
hardworking etc.
Personality disorders result when these
personality traits become abnormal. i.e. when it
disrupts the personal life of the individual or show
deleterious effects on the society or the family.
 Although personality disorders are usually
recongnisable by early adolescence, they
are not diagnosed before early adulthood.

Types:
1. Paranoid personality disorder:
These patients show excessive
suspiciousness. Does not trust friends or
family members. They get involved in
litigation on small issues.
2. Schizoid personality disorder:
* Patient is aloof by nature
* No desire for close relationship
* Does not show emotional attachment to
friends or family members.
* Indifferent to praise or criticism.

3. Dissocial Personality Disorder:

* Disregard for rules of society
* Repeated breaking of laws by lying, cheating
or violence.
* No remorse or guilt when caught.
4. Emotionally unstable personality:
* Tendency to act impulsively
* Emotionally instable
* Prone to outbursts of violence
* Has chronic feelings of emptiness
* Short lasting relationships.

5. Histrionic personality Disorder:

* Excessive emotional and attention
seeking behaviour.
* Unable to develop deep relationship.
6. Anxious personality disorder:
* Shy and socially inhibited
* Feelings of inferiority
* Hypersensitive to rejection

7. Dependent personality disorder:

* Excessively dependent on others.
* Not able to function alone.
* Can not take any decision alone.
* Submissive
8. Anankastic personality disorder:
* Preoccupied with orderliness and
cleanliness.
* Lack Flexibility
* Rigid about morality and ethics
* Stingy and stubborn
 Personality Disorder

Cluster A Cluster B Cluster C

* Paranoid * Emotionally * Anxious

* Schizoid Unstable * Dependent

* Dissocial * Histrionic * Anankastic