Dissociative Disorders, Conversion Disorder and Somatic Symptoms

All disorders, namely Dissociative Disorders, Conversion Disorders, Somatic Symptoms, and Related Disorders, were previously classified as hysteria. In these disorders, the patient presents with certain symptoms without any bodily cause. Upon thorough examination and investigation, everything seems normal. An associated stressor is generally present. Conversion disorders in ICD-11 have been placed under Dissociative disorders. In the DSM-5, they are placed under somatic symptoms and related disorders.

Dissociative Disorders

• There is a disturbance in one or more mental functions, such as memory, identity, perception, consciousness, or motor behavior.
• Whenever there is too much stress, the mind or the psyche produces certain symptoms to relieve anxiety and resolve unconscious conflicts.
• These symptoms are produced unconsciously. So, whenever a person experiences certain symptoms, and everything seems normal, the person is most likely not faking these symptoms.
• The person is experiencing these symptoms but is unaware that the mind produces these symptoms.
• The onset of these symptoms is usually sudden, and often, they are precipitated or caused by some psychological trauma or stress.
• There are various gains in dissociative disorders:

1. Primary Gains

• The primary gain is achieved by keeping the internal conflicts outside the awareness. It is done unconsciously by producing the symptoms which reduce the internal conflicts. These are internal gains. For example, a person has an exam in the coming days. There is a lot of stress and anxiety related to this, and suddenly, one day, the person reports that they're unable to see anything, i.e., he has developed blindness. So, this symptom of blindness has reduced or kept those unconscious conflicts of anxiety away from his awareness.
• Now, the person is more concerned about his blindness than about studies or exams, so this is the primary gain.

2. Secondary Gains

• Secondary gains are advantages or benefits a person gets as a result of getting sick. 
• These are external gains.

3. Tertiary Gains

• Tertiary gains are gains derived from significant others, people, or family members close to the patient because of the patient's symptoms.
• For example, the parents may receive money from relatives for the expenditure or treatment or relief from their offices to take care of the patient.

Epidemiology of Dissociative Disorders

• There are a very limited number of studies done on dissociative disorders, and usually, it is seen that the prevalence in males and females is the same.
• But, in certain conditions, females show more prevalence, like in conversion disorders in dissociative identity disorder, which is multiple personality disorder.
• Males may have more prevalence in disorders like Ganser syndrome.

Dissociative Amnesia

• It is amnesia, which means loss of memory. It is an inability to recall important personal information, usually from a traumatic event.
• It is inconsistent with ordinary forgetting.
• Amnesia is also seen in disorders like dementia. But there is some bodily cause that is causing the symptoms. Here, there is no such cause.
• For example, a person is rescued two days after his kidnapping. He is unable to recall any information about those two days. So when the police or the family members ask, he is not able to remember everything. However, he remembers everything before those two days and everything thereafter. It happened because there was too much stress. His mind has dissociated or disintegrated some part of their memory from the other functions. This is dissociative amnesia.

Dissociative Fugue

• A dissociative fugue is a sudden, unexpected travel away from home or the workplace. So this travel is more than the normal travel which we do. 
• Fugue means to run away.
• For example, a person may travel from one city to another. The person is unable to recall some or all of one's past. So, a component of amnesia is also there.
• The person may be confused about their identity or assume a new identity. Though, a person is able to maintain their basic self care during a fugue state. In DSM-5, the dissociative fugue is no longer a separate diagnosis but a specifier of dissociative amnesia. Similar changes have been made in ICD 11.

Trance Disorder

• It is characterized by a trance states in which there are marked changes in the person's state of consciousness or, there is a loss of sense of personal identity.
• There's a narrowing of awareness of the surroundings associated with restrictions of movements and speech experienced as being out of one's control.
• There's no experience of being replaced by an alternate identity.
• It's just that a person may not be able to recall certain activities he did in the past.

Possession Trance Disorder

• It is characterized by a trance state in which there are marked changes in the person's state of consciousness.
• There's an experience of being replaced by an alternate identity.
• The individual's behavior is expressed as being controlled by the possessing identity.
• For example, A newly married claims that the spirit of a dead grandmother has possessed her and during that state, she says to her in-laws to take good care of her, and she does certain behaviors. She talks in a different voice. She may later claim that she was not aware of whatever happened.

Depersonalization-Derealization Disorder 

• There are recurrent experiences of depersonalization or derealization or both.
  • Depersonalization: It is a feeling of detachment from the self. The person feels as if the self is unreal. The person may feel like he is watching themselves from outside the body, like watching a movie.
  • Derealization: It is a feeling of detachment from the world. The person feels as if the world is unreal.
• In these disorders, reality testing is intact. The person knows what's real and what's unreal.
• Differential Diagnosis of depersonalization - derealization disorder
  • These symptoms can often be seen in other disorders like Seizure Disorders, migraines, substance use like Cannabis and Lysergic Acid Diethylamide (LSD), and head injury.
• The symptoms of depersonalization and derealization are very common. They're the 3rd most common psychiatric symptoms.

Dissociative Identity Disorder (Multiple Personality Disorder)

• In this disorder, two or more distinct personalities exist in one individual, with only one of them evident at a time.
• The personalities are also known as alters, having their own pattern of thinking and behaving.
• The alters are usually unaware of each other's existence.
• For example, There's a person named Ms. P. She returns home and sees herself with strangers in photos on her social media profile. In photos, she appears to know them and spends a good amount of time with them but cannot remember any of them. Here, her first identity has gone through that experience, but her second identity doesn't know anything about it.
• More than two personalities are possible as well.

Conversion Disorder

• ICD-11 places it under dissociative disorders and is known as Dissociative Neurological Symptom Disorder (DNSD).
• In DSM-5, it is known as Functional Neurological Symptom Disorder and is classified under Somatic Symptom Disorder.
• The patient has certain neurological symptoms that seem to be functional in nature.
• So, predominantly, the symptoms of conversion disorder are neurological in nature.
• Epidemiology:
  • More in females than males, and generally, the onset occurs in late childhood to early adulthood.
• In conversion disorder, a patient presents with symptoms suggestive of a deficit in motor or sensory functions or both. So, there is somebody who is at a deficit in certain neurological symptoms but without any evidence of any physical disorder.
• The symptoms are neurological, but there is no neurological cause. The reason is that too much stress has converted the stress into these neurological symptoms.
• At times, the symptoms are inconsistent with the body's anatomy and physiology, such as inconsistent tremors.
• Symptoms may be sensory or motor in conversion disorder.

La Belle Indifference

• La belle indifference is associated with conversion disorder. It includes the patient's inappropriately careless attitude towards serious symptoms. 
• For instance, the girl who is not able to see may be sitting very calmly.

Other Dissociative Disorders

• Ganser Syndrome: the hallmark symptom is that a patient may give approximate answers (VORBEIGEHN). The patient's reply often misses the mark but bears some obvious relation to the question, indicating that the question was understood.
• Other symptoms of Ganser syndrome may include the following:
  • Clouding of consciousness
  • Visual or auditory hallucinations can also be present
• During initial recognition, it was seen more in prisoners (Gangsters).
  • It can be seen in other populations as well.
• Treatments
  • Psychotherapy
    • Behavior Therapy: Here, the focus is on current symptoms. The patient is not encouraged to assume the sick role.
  • Abreaction: It is bringing the unconscious memories and emotions to the awareness of the patient using hypnosis, free association and drugs like thiopentone, amobarbital, diazepam, etc.
  • Psychodynamic Psychotherapy is also used.
  • Pharmacotherapy
    • It has a very limited role in the treatment of dissociative disorders.
    • Benzodiazepines can be used for a short-term duration in case of anxiety and SSRI (Selective Serotonin Reuptake Inhibitor), especially for depression.

Somatic Symptoms and Related Disorders

• These were previously known as somatoform disorders.
• The patient presents with somatic (physical) symptoms which lead to significant distress or impairment.
• There's no medical cause of these disorders. They're often called “Medically Unexplained Symptoms” or MUS.

Somatic Symptom Disorder

• It was previously known as somatization disorder.
• It's also called Briquet's syndrome.
• ICD-11 uses the term “bodily distress disorder” for this disorder.
• The person is preoccupied with somatic symptoms. It may be in the form of excessive thoughts, feelings, or behaviors related to those symptoms.
• The duration generally is more than 6 months.
• There's a specifier associated, which is predominant pain.
• Previously, it was separately diagnosed as a pain disorder.
• There may be an association between the symptoms and psychosocial stressors.
• The patient may complain of fatigue, nausea, pain, etc.

Illness Anxiety Disorder (DSM-5) or Hypochondriasis (ICD-11)

• The patient is preoccupied with having or acquiring a serious illness.
• The somatic symptoms are either absent or mild.
• The duration of this disorder is more than six months.
• It's the anxiety of having a serious illness. For example, the patient may correlate a headache with a brain tumor.
• The preoccupation persists despite normal investigations and reassurances by the doctor.
• In delusional disorder (somatic), the patient's belief is fixed, whereas in the case of Hypochondriasis, a patient may doubt his belief for a short duration. It may happen even after several reassurances by doctors.

Factitious Disorder

• Factitious disorder is also known as Munchausen syndrome.
• The patient produces fake physical or psychological symptoms to assume a sick role with the aim of receiving medical attention.
• The deception may involve giving a false history of symptoms, contamination of laboratory samples, induction of symptoms, or injury.
• For example, the patient may add sugar to the urine sample, consume some psychoactive substance, or induce injury marks. Richard Asher coined the term Munchausen syndrome after a Russian military officer, Baron Von Munchausen, who often told stories of his bravery.
• There are other names for this syndrome, like Hospital Addiction and Professional Patient Syndrome.
• The patient also suffers from Pseudologia Fantastica, where patients distort their history and tell false details to convince doctors of having certain symptoms.
• With time, these patients become very knowledgeable about medicine and hospitals.
• The symptoms may be psychological or physical.

Factitious Disorder Imposed on Another

• It is also known as Factitious disorder by proxy or Munchausen syndrome by proxy.
• A person (usually a caretaker) produces symptoms in another person to gain medical attention. It can either be by indirectly assuming the sick role or by being relieved of the caretaking role.
• It most commonly involves a mother deceiving that her child is ill and persuading the doctor to admit the child.
• The deliberate falsification of symptoms can be done either to receive medical attention or for external gains/benefits.
• In the former case, it's a factitious disorder requiring a psychiatric diagnosis. In the latter case, it is known as malingering, which is not a psychiatric diagnosis.

Malingering

• Malingering involves producing symptoms for financial gains like insurance claims, avoiding work, military duty, or legal cases.
• Malingering should be suspected if:
  • There's a medicolegal involvement. For example, if a court refers a patient.
  • Also, the patient should be suspected of an evident discrepancy between the alleged symptoms and objective findings.
  • Lack of cooperation during diagnostic evaluation and treatment.
  • There's the presence of antisocial personality disorder.

Body Integrity Dysphoria

• There's a new diagnosis in ICD-11 known as Body Integrity Dysphoria.
• There's an intense and persistent desire to become disabled in a significant way. For example, a desire for limb amputation, to become paraplegic or blind.
• There's a discomfort with a current non-disabled body part.
• The patient is preoccupied with becoming physically disabled.
• They may either pretend or attempt to become disabled.
• The onset of this disorder is by early adolescence.

Also Read: Nymphomania: Causes, Symptoms, Risk Factors, Diagnosis, Treatment

Psychological Factors Affecting Other Medical Conditions

• The concept of psychosomatic medicine is incorporated into this diagnosis. Basically, psychological factors cause or aggravate physical disorders.
• It covers physical disorders caused by or adversely affected by psychological factors.
• A medical disorder must be present to make the diagnosis.
• Some examples include anxiety, exacerbating asthma, chronic occupational stress, or increased risk of hypertension.

Stress-Related Disorders

• A circumstance that disturbs or is likely to disturb the normal psychological or physiological functioning of a person.
• Sometimes, stress is important in doing certain types of work.
• Hans Selye believed that stress could be pleasant (Eustress) or unpleasant (DIstress). Hans Selye developed a model of stress known as General Adaptation Syndrome.
• It has three phases:
  • The stage of Alarm Reaction is an immediate fight-or-flight response to a situation. A person visiting a cold place may either try to run away or stay put.
  • Stage of Resistance: In this stage, adaption is achieved. A person's body tries to adapt to a situation physiologically.
  • Stage of Exhaustion: The acquired adaptation either decreases or may be lost.

Specific Organ Systems Involved When a Person is Stressed

• Gastrointestinal system: Many GI disorders are affected by psychological factors such as peptic ulcers, ulcerative colitis, Crohn's disease, and irritable bowel syndrome.
• Cardiovascular diseases: These may include hypertension, coronary artery disease, and sudden death.
  • Type A personality: These people are very competitive, impatient, and aggressive with time urgency. There's a two-fold risk of cardiac infarction or coronary artery disease-related mortality.
  • Type B personality: These individuals are calm and relaxed and at a lower risk of coronary vascular diseases.
• Respiratory System: This includes diseases like asthma, hyperventilation syndrome, COPD, etc., which are associated with psychological disorders.
• Other disorders may also have psychological factors:
  • Endocrine System: Hypothyroidism and hyperthyroidism, Diabetes Mellitus, adrenal disorders, etc.
  • Muscular Disorders: Rheumatoid Arthritis and SLE.
  • Skin Disorders: Psoriasis and atopic dermatitis may also be associated.
  • Headaches may also have a psychological cause.

Pseudocyesis

• Pseudocyesis is a false belief of being pregnant. 
• It is associated with objective signs and reported symptoms of pregnancy.
• There may be abdominal enlargement, breast engorgement, amenorrhea, and labor pains.
• Treatment of Pseudocyesis
  • These patients may not be open to psychiatric treatment because of evident physical signs.
  • Psychotherapy involves acknowledging that these symptoms are not real. It's also important to clarify the role of psychological factors in causing these symptoms.
  • Cognitive Behavior Therapy is a preferred modality of treatment. It involves identifying thoughts that increase stress and using behavioral techniques like relaxation.
  • Other therapies like Group therapy, Psychodynamic psychotherapy, Stress management, and Relaxation therapy also play some role in these disorders.

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