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MRCPsych Lecture 13.09.11
A Chakraborti
[email protected]
Dissociation – disturbance in the normally integrated functions of identity, memory,
consciousness, behaviour, thoughts, feelings, emotions and the unitary sense of self and
personality (Mental functions). Psychogenic, a/w stress, acute and spontaneous. Neurotic
Defense Mechanism.
Conversion – appearance of physical illness that do not conform to current concepts of
organic pathology; related to CNS, PNS, ANS. Psychogenic, a/w stress, acute and
spontaneous. Psychological converted to physical.
Somatisation – tendency to experience and communicate somatic distress in response to
psychosocial stress and to seek medical help for it. Immature Defense Mechanism.
Manifestation of Affective Ds, Anxiety, Somatoform Ds.
Somatisation Disorder – chronic, polysystematic, polysymptomatic, psychosomatic
neurosis. g.i, cvs, gu, dermat & pain. Physical attribution & consulting behavior.
Hypochondriasis – persistent belief/preoccupation/fear of serious physical disease or
presumed excessive defect in appearance.
Hysteria – ‘wandering womb’. included conversion, somatisation and dissociation
Concepts & Definitions
Depersonalization – subjective, ‘as if’ experience, distortions of time, of sensory
experience, emotional numbing, but patient is aware of the change; its not a
psychotic or personality disturbance eg schizophrenia or dissociative ds or dementia.
Should not be used as main diagnosis if it arises in the context of any other disorder.
Delusion – conviction, extension, bizarreness, disorganization, concern, affective
response, deviant behavior. (cf: somatic delusions, delusional dysmorphophobia)
Artefactual illness – psychological or physical signs or symptoms are not real,
genuine or natural but produced voluntarily or feigned. Aim is to adopt a sick role,
and motives are presumed to be internal. aka Factitious ds, deliberate disability,
Münchhausen’s syndrome, Ganser’s syndrome or pseudodementia. May include
self-inflicted harm – abscess production, haematuria, insulin overdose.
Malingering – external incentives for above behavior recognizable inc. economic
gain, obtaining drugs, avoiding work, prosecution, duty, or improving physical wellbeing.
Concepts & Definitions
Culturally sanctioned behavior – The term culture-bound syndrome denotes recurrent, localityspecific patterns of aberrant behavior and troubling experience that may or may not be linked to
a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered
to be “illnesses,” or at least afflictions, and most have local names. Although presentations
conforming to the major DSM-IV categories can be found throughout the world, the particular
symptoms, course, and social response are very often influenced by local cultural factors. In
contrast, culture-bound syndromes are generally limited to specific societies or culture areas
and are localized, folk, diagnostic categories that frame coherent meanings for certain
repetitive, patterned, and troubling sets of experiences and observations.
Histrionic personality disorder – ICD F60.4 & DSM Axis II Cluster B –
Pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a
variety of contexts,‘PRAISE ME’
P - provocative (or seductive) behavior
R - relationships, considered more intimate than they are
A - attention, must be at center of
I - influenced easily
S - speech (style) - wants to impress, lacks detail
E - emotional lability, shallowness
M - make-up - physical appearance used to draw attention to self
E - exaggerated emotions - theatrical
Concepts & Definitions
International Classification of Mental
& Behavioral Disorders – version 10,
chapter V (WHO 1992)
Diagnostic and Statistical Manual of
Mental Disorders – fourth edition,
text revision (APA 2000)
Uses separate category of Dissociative
(Conversion) Disorder (akin to
Hysteria) and includes –
D Amnesia (F44.0), D Fugue (F44.1),
Stupor (.2), Trance & Possession
States (.3), Motor Disorders (.4),
Convulsions (.5), Anesthesia &
sensory loss (.6), Mixed D(C) Ds (.7),
Other D(C) (.8) including Ganser’s
(.80) - moved from Factitious,
Multiple Personality Disorder (.81),
Transient D(C) Ds occurring in C&A
(.82), Other specified (.88);
D(C) Ds, unspecified (F44.9)
Dissociative Disorders is a separate
generic category, and includes –
D Amnesia (300.12), D Fugue
(300.13), D Identity Disorder (300.14),
D NOS (300.15)
Depersonalization Disorder is also
included (300.6)
Conversion Disorder (300.11) is listed
under Somatoform Disorders along
with Somatisation Disorder,
Somatoform Pain Disorder,
Hypochondriasis and Body
Dysmorphic Disorder.
ICD 10 v/s DSM IV
D Amnesia – loss of memory including important recent events
usually of stressful nature, selective or complete loss. Exclude
organic, other dissociative disorders, PTSD, subst, GMC,
amnesia. Confabulation & self-monitoring may occur.
(cf: Transient Global Amnesia – older popu, vasospastic/TIA
linked, retrograde amnesia+anterograde during episode, sufferer is
more upset, personal identity and complex mental/performance
intact, generalised memory loss with temporal gradient)
D Fugue – acute, unexpected but organised travel, journey amnesia,
complete or partial new identity (DSM), self-care ok, unaware of
loss, psychogenic process, exclude organic
D Stupor – profound diminution or absence of voluntary movements
&speech &of normal responses to light, noise &touch. Normal
muscle tone, static posture, breathing (& often limited coordinated
eye movements) are maintained. Exclude organic, catatonic,
depressive, manic stupor
Trance & Possession –
1. Trance -temporary alteration of state of consciousness a/w loss of
sense of personal identity, narrowing of awareness of
environmental stimuli, repetition of a small repertoire of
movements, postures and speech
2. Possession –a/w conviction that s/he has been taken over
Unwanted, troublesome experience outside of similar states in
religious/cultural contexts. Exclude F20s & F30s
D Motor Ds
D Convulsions
D Sensory loss
Complete or
partial loss of
under voluntary
control –
1/3rd epileptic
No LoC, may
suffer with
stupor – gag &
pupillary reflex
retained. Other
features similar
– rare bites &
Cutaneous &/or
Vision, hearing,
Stocking &
glove type
Cortical evoked
potential are
Mixed D(C) Ds
Twilight state
F 44.4 to 44.8 = Conversion
Imp: to have convincing association in time between onset of symptoms &
stressful events. Repression as defense mechanism. 90-100% resolve <1/12.
Impaired hemispheric communication & elevated corticofugal output.
ICD includes loss of sensations; additional sensations eg pain or ANS
mediated are included under Somatoform (F 45)
Symptoms generally represent patients concept of the physical disorder
Significant minority may later be diagnosed with neurological disorders.
• Primary Gain – achieve primary gain by keeping internal
conflicts outside of awareness.
• Secondary Gain – tangible advantages & benefits of sick
role: excuse from obligations, situations, receive support
not otherwise forthcoming, controlling other’s behaviour.
• La belle indifference – inappropriately cavalier attitude
towards serious condition; not consistently associated.
• Identification – unconsciously model their symptoms on
someone important to them inc. someone recently dead.
Associated Features
• Ganser’s syndrome – very rare, vorbeigehen (to pass by) or
approximate answers, clouding of consciousness, somatic
conversion symptoms, pseudohallucinations.
• Combat hysteria – dissociative and/or conversion d/t severe stress
• Epidemic hysteria – large groups similarly disposed or
institutionalized (under some level of stress)
• Hysterical psychosis – sudden, psychogenic trauma, patient’s own
idea of psychosis (Acute, polymorphic, non-schizophrenic F23)
• Culture-bound – Latah, Amok, Pibloktoq
• Multiple Personality F44.81 - ≥ 2 distinct personalities, each with
own behavior, memories, preferences. ‘one-way amnesia’ A
unaware of B, B knows A. Disputed diagnosis. F>M. Insight
oriented psychotherapy.
Other Dissociative States