Transcript Chapter 10：Conversion and dissociation

Chapter 10
Conversion and dissociation
Zhonghua Su
Jining Medical University
Main elements
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they lack evidence of proximate organic illness or
pathophysiological disturbance;
the symptoms correspond to ideas of the patient
about how parts of the body or mind malfunction or
fail to function.
The most representative examples：
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blindness, deafness, paralysis, loss of speech, and certain
types of memory disturbance, including fugue states.
global memory loss.
Neither are they due to delusions or hallucinations as
conventionally defined.
History
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2000前，的埃及记载：hysteria为子宫之意；
希腊历史学家Herodote和医学家Hippocrates的类似看法；
1618年，Charles Lepois：癔症在脑而非子宫；
1859年，Briquet综合征（430 cases）；
1886年，Charcot提出癔症可为催眠引起或消除，遗传有关；
1885年，Freud，《癔症的研究》
1898年，Ganser描述了Ganser综合征、假性痴呆和童样痴
呆
1950’s，癔症误诊精神分裂症、心境障碍、人格障碍、酒
精中毒、药物依赖、焦虑症
History
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The recognition of the relevance of emotion and motive to
bodily and mental symptoms is as old as Hippocrates and Galen.
Reynolds and Charcot recognized that hysteria depended upon
an idea, but the way in which the idea works is another matter.
At the start of the First World War the conditions that we now
call conversion and dissociative disorders were common.
The original Freudian theory suggested that ideas which were
completely absent from the patient's memory in a normal state,
or present only in ‘a highly summary form', could be revealed by
hypnosis.
Current meaning
hysterical symptoms arose from the conversion of
emotional energy to a physical symptom
 unconscious motives and emotional conflict
 a split in mental processes
 a disruption in the integrated
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Epidemiology (1)
22 /100,000
 5 -15% of psychiatric consultations in a general
hospital
 25-30% percent of admissions to a Veterans
Administration hospital
 Woman: Men 2 :1 or 5 :1
 onset at any time
 most common among rural populations
 commonly associated with comorbid diagnoses of
major depressive disorder, anxiety disorders, and
schizophrenia.
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Epidemiology (2)
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Dissociative amnesia
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most common dissociative symptom;
occurs in almost all the dissociative disorders;
occur more often in women than in men and more often in
young adults than in older adults;
usually associated with stressful and traumatic events;
Dissociative fugue is rare
 Dissociative Identity Disorder
 transient depersonalization
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诊断分类
癔症(40)、应激相关障碍、神经症
（CCMD－3）
癔症性精神障碍40.1
 癔症性躯体障碍40.2
 癔症性躯体－精神障碍40.3
 其他或待分类的癔症40.9
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Ganser’s综合征40.91
见于儿童和青少年短暂的癔症性障碍
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癔症性精神障碍
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40.1
癔症性遗忘
癔症性漫游
癔症性身份识别障碍
癔症性精神病
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40.11
40.12
40.13
40.14
40.141
癔症性附体障碍
 与文化相关的癔症性附体障碍
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40.1411
40.142
癔症性木僵
癔症性感觉障碍
40.2
癔症性运动障碍
癔症性抽搐发作
癔症性感觉障碍
40.21
40.22
40.23
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分离（转换）性障碍（F44）
（ICD－10）
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分离性遗忘
分离性漫游
分离性木僵
出神与附体障碍
分离性运动障碍
分离性抽搐
分离性感觉麻木和感觉丧失
混合性分离（转换）性障碍
其它分离（转换）性障碍
分离（转换）性障碍，未特定
F44.0
F44.1
F44.2
F44.3
F44.4
F44.5
F44.6
F44.7
F44.8
F44.9
DSM－IV
躯体形式障碍
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300.81躯体化障碍
300.81未分化的躯体形式
障碍
300.11转换障碍
307.XX疼痛障碍
疑病症
躯体变形障碍
未加标明的躯体形式障碍
分离性障碍
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300.12分离性遗忘症
300.13分离性神游症
300.14分离性身份障碍
300.6 人格解体障碍
300.15未加表明的分离性
障碍
转换障碍（DSM－IV）
A. 影响着自主运动或感觉功能，并提示是一种神经系或其他一般躯体
情况的一种以上症状。
B. 可以判断有心理因素伴随于这些症状或缺陷，因为在症状的发生或
恶化之前都有心理冲突或其他应激。
C. 这些症状或缺陷都不是有意识地产生或伪装的（如人为性障碍或诈
病）。
D. 在适当的调查了解后，可以发现这些症状或缺陷不可能用一般躯体
情况或某种物质的直接效应来解释的，也不象其文化所认可的行为
或体验。
E. 这些症状或缺陷产生了临床上明显的痛苦烦恼或在社交、职业、或
其他重要方面的功能缺损，或者要找内外科作出评价保证。
F. 这些症状缺陷不限于疼痛或性功能失调，可以排除是在躯体化障碍
中发生的，也不可能归于其他精神障碍。
标明：具有运动症状或缺损
具有感觉症状或缺损
具有癫痫发作或抽搐
具有混合的表现
DSM－2－R
神经症40
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恐怖性神经症40.0
焦虑性神经症40.1
强迫性神经症40.2
抑郁性神经症40.3
癔症40.4
神经衰弱40.5
其它神经症40.8
癔症40.4
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癔症性遗忘40.40
癔症性漫游40.41
癔症性身份识别障碍40.42
癔症性精神病
癔症性转换障碍40.44
其它癔症性障碍40.48
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如Ganser’s综合征
未特定性癔症40.49
Clinical features
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Conversion disorder
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Sensory Symptoms
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Motor Symptoms
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感觉过敏或缺乏
视觉、听觉障碍
癔症球
植物神经和内脏功能障碍
心因性疼痛
癔症性失音
癔症性瘫痪
起立不能、运动不能
肢体震颤、抽动和肌阵挛
Seizure Symptoms
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Dissociative disorder
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Stupor
Amnesia
Fugue
Dissociative identity
disorder
Recovered Memory Syndrome
Ganser's Syndrome
情感爆发
意识朦胧状态
恍惚状态和附体状态
癔症性精神病
Sensory symptoms
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Anesthesia and paresthesia are common, especially of the
extremities.
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Distribution of the disturbance is in consistent
Characteristic anesthesia:
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stocking-and-glove anesthesia of the hands or feet
the hemianesthesia of the body
organs of special sense: deafness, blindness, and tunnel vision.
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be unilateral or bilateral;
walk around without collisions or self-injury
pupils react to light is normal
their cortical evoked potentials is normal
Motor symptoms
include abnormal movements, gait disturbance,
weakness, and paralysis.
 worsen when attention is called to them.
 rarely fall; if they do, they are generally not injured.
 paralysis and paresis involving one, two, or all four
limbs
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Reflexes remain normal;
no fasciculations or muscle atrophy
electromyography findings are normal.
Seizure Symptoms
最常见大发作（农村1/2，住院患者1/5）
 常于情绪激动/受到暗示时突然发生
 突然跌倒，手足抽动，屏气/过度换气，问之不答，
但无意识障碍
 发作时：
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无强直阵挛
几乎没有咬伤，跌伤，尿失禁
角膜反射良好
无伸性柘反射
发作后，无催乳素水平增加
Stupor
常为精神创伤体验所触发/发生于精神创伤之后
 突然发生的自主运动减少或丧失
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在相当长的时间内维持固定的姿势，没有言语和随意
运动；
但是，对光线、声音或疼痛刺激反应正常；
肌张力、姿势和呼吸可无明显异常，眼球向下转动/紧
闭双眼；
出现较深的意识障碍，既非入睡，也不是昏迷状态，10
余分钟自行缓解；
精神分裂症紧张型、抑郁性木僵鉴别
Amnesia
对自己经历的重大事件突然失去记忆，常与精神
创伤有关；
 常无脑器质性损害（个别除外）；
 may not know who he is, but knows who is the Queen,
the President, or his doctor.
 Unaware of his own personal history, he may yet play
chess well, speak one or two languages, read the
newspaper, and so forth.
 常就诊于神经科
 more frequent amongst criminals or soldiers in distress.
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分离性遗忘（DSM－IV）
A.
B.
C.
The predominant disturbance is one or
more episodes of inability to recall
important personal information, usually of
a traumatic or stressful nature, that is too
extensive to be explained by ordinary
forgetfulness.
The disturbance does not occur exclusively
as a symptom of dissociative identity
disorder, dissociative fugue, posttraumatic
stress disorder, acute stress disorder, or
somatization disorder and is not due to the
direct physiolgoical effects of a substance
(eg, a drug of abuse, a medication) or a
neurological or other general medical
condition (eg, amnestic disorder due to
head trauma).
The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
A.
明显突出的障碍是：一次以上的发作，
发作时不能回忆重要的个人问题；往
往属于创伤性或应激性质，而且太过
分以致不能用通常的健忘来解释。
B.
这种障碍并非发生于分离性身份障碍、
分离性漫游、创伤后应激障碍、急性
应激障碍、或躯体化精神障碍的病程
之中，也不是由于某种物质（例如滥
用药物、治疗药品），或某种神经系
或其他一般躯体情况，（例如颅脑外
伤所致遗忘性障碍）所致之直接生理
效应。
C.
这些症状产生了临床上明显的痛苦烦
恼、或在社交、职业、或其他重要方
面的功能缺损。
Fugue
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突然从家中或单位出走，到外地旅行。地点可能是以往熟
悉或有情感意义的地方。
此时意识范围缩小：
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但保持基本生活能力和简单的社会接触交往能力；
外人看不出其言行和外表有明显异常。
历时几十分钟到几天，常突然清醒。
事后难以回忆。
Fugue : organic fugue
Fugue : postical states
10 of 25: epilepsy, 1 with schizophrenia, several others had
depression (Stengel)
分离性漫游（DSM－IV）
A.
B.
C.
D.
The predominant disturbance is sudden,
unexpected travel away from home or
one's customary place of work, with
inability to recall one's past.
Confusion about personal identity or
assumption of a new identity (partial or
complete).
The disturbance does not occur exclusively
during the course of dissociative identity
disorder and is not due to the direct
physiological effects of a substance (eg, a
drug of abuse, a medication) or a general
medical condition (eg, temporal lobe
epilepsy).
The symptoms cause clinically significant
distress or impairment in social,
occupational, or other important areas of
functioning.
A.
突然、出乎意料地离家或离开平常工
作单位出外旅行，而不能回忆自己的
过去。
B.
.对于个人的身份搞不清楚，或假设了
一种新的身份（部分的或全部的）。
C.
此障碍并非发生于分离住身份障碍的
病程中，也不是由于某种物质（例如，
某种滥用药物，治疗药品）或一般躯
体情况（例如，颇叶癫痫）所致之直
接生理性效应。
D.
这些症状产生了临床上明显的痛苦烦
恼，或在社交、职业、或其他重要方
面的功能缺损。
Dissociative identity disorder
formerly multiple personality disorder
 患者突然失去对自己往事的全部记忆，对自己原
来的身份不能识别，以另一种身份进行日常社会
活动。
 表现为两种或两种以上明显不同的人格，各有其
记忆、爱好和行为方式，完全独立，交替出现，
互不联系，在某一时刻只是显示其中一种人格，
此时意识不到另一种人格的存在。
 初次发病突然，与精神创伤有关；以后发病，可
由联想或特殊生活事件触发。
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分离性身份障碍（DSM－IV）
A.
B.
C.
D.
The presence of two or more distinct
identities or personality states (each with
its own relatively enduring pattern of
perceiving, relating to, and thinking about
the environment and self).
At least two of these identities or
personality states recurrently take control
of the person's behavior.
Unability to recall important personal
information that is too extensive to be
explained by ordinary forgetfulness.
The disturbance is not due to the direct
physiological effects of a substance (eg,
blackouts or chaotic behavior during
alcohol intoxication) or a general medical
condition (eg, complex partial seizures).
Note: In children, the symptoms are not
attributable to imaginary playmates or
other fantasy play.
A.
存在2种以上明显的身份或人格（每一
种都有他自己相对长久的对环境和自
我的认识、关系、或想法）。
B.
至少有2种这种身份或人格反复地控制
他的行为。
C.
不能回忆重要的个人问题，而且太广
泛以致不能用通常的健忘来解释。
D.
此障碍不是由于某种物质（例如急性
酒中毒时的黑懵或混乱行为）或一般
躯体情况（例如复合性部分性抽搐）
所致之直接生理性效应。
注：如是儿童，症状并非由于想像性
的游戏伙伴或其他幻想性游戏。
Conversion Disorder（1）
A.
B.
C.
One or more symptoms or
deficits affecting voluntary motor
or sensory function that suggest
a neorological or other GMC
Psychological factors are judged
to be associated with the
symptom or deficit because the
initiation or exacerbation of the
symptom or deficit is preceded
by conflicts or other stressors
The symptom or deficit is not
intentionally feigned (as in
Factitious Disorder or
Malingering)
A.
有一种或多种影响随意运动或
感觉功能，并提示为神经系统
或其他躯体情况的症状或缺损；
B.
因为症状或缺损出现或恶化以
前有心理冲突或其他应激因素，
所以可以判断心理因素与这些
症状或缺损有关
C.
这些症状或缺损不是有意制造
或假装的（如在做作性障碍或
诈病时那样）
Conversion Disorder（2）
D. The symptom or deficit cannot, after
appropriate investigation, be fully
explained by a general medical
condition, or by the direct effects of
a substance, or as a culturally
sanctioned behavior or experience
E. The symptom or deficit causes clinically
significant distress or impairment in
functioning
F. The symptom or deficit is not limited to
pain or sexual dysfunction, does not
occur exclusively during the course
of Somatization Disorder, and is not
better accounted for by another
mental disorder
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经过适当的调查后，这些症状
或缺损不能完全用已知的躯体
情况、物质直接效应或文化认
可的行为或体验来解释

这些症状或缺损引起具有临床
显著意义的苦恼或社交、职业、
其它功能损害，或称为患者就
诊的理由

这些症状或缺损不限于疼痛或
性功能失调，不仅发生与躯体
化障碍的病程中，不能用其他
精神障碍解释。
表明
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Specify type of symptom
of deficit:
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With motor symptom or
deficit
With sensory symptom or
deficit
With seizures or convulsions
With mixed presentation
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表明
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具有运动症状或缺损（如，
共济失调、麻痹或局部无力、
吞咽困难或“喉头有团块”
感、失音、尿潴留）
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具有感觉症状或缺损（如触
觉或痛觉丧失、复视、盲、
聋、幻觉）
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具有癫痫发作或抽搐（包括
具有随意运动或感觉成份的
癫痫样发作或抽搐）
具有混合性表现
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Differential diagnosis （1）
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Conversion disorder
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ruling out a medical disorder.
Neurological disorders
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dementia and other degenerative diseases
brain tumors
basal ganglia disease
schizophrenia, depressive disorders, and anxiety disorders
somatization disorder.
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somatization disorder
hypochondriasis
pain disorder
sexual dysfunction
Differential diagnosis （2）
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Dissociative amnesia
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Amnesia associated with
dementia and delirium
head trauma
Epilepsy
Dissociative fugue
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dissociative amnesia
schizophrenia
rapidly cycling bipolar
disorders
Borderline personality disorder
Malingering
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Dissociative identity
disorder
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depressive disorders and
schizophrenia
psychotomimetic drugs
Prognosis
In general the prognosis for symptoms of acute
conversion or dissociation is good but that for longerlasting symptoms is relatively poor.
 The prognosis for monosymptomatic conversion is
usually good
 suicide rate among men was similar to that in the
general population, but the rate for women was higher
 a third of patients had improved at follow-up, a third
were unchanged, and a third were worse
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Treatment
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心理治疗
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暗示治疗
催眠治疗
解释性心理治疗
分析性心理治疗
行为治疗
疏泄治疗
家庭治疗
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药物和物理治疗
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抗精神病药物治疗
抗抑郁药物治疗
抗焦虑药物治疗
针刺或电刺激治疗
Treatment
Most patients with conversion symptoms are managed
by general practitioners
 Symptoms may be minor, short lived, or self-limiting
 Brief psychotherapy may be helpful
 intensive psychodynamic psychotherapy is unlikely to
be useful
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