F44

CONVERSION DISORDER
 Conversion disorder is define as a
psychiatric condition in which
emotional distress or unconscious
conflicts are expressed through
physical symptoms.

 Thus emotional conflicts is converted

into physical symptoms.
 F44
CONVERSION DISORDER
 Conversion disorder is a loss of or change in body function
resulting from a psychological conflict.

 The physical symptoms of which cannot be explained by any

known medical disorder or pathophysiological mechanism.

 Conversion symptoms affect voluntary motor or sensory

functioning suggestive of neurological disease such as blindness
or paralysis.

 Are therefore sometimes called “pseudo neurological”

 F44
CONVERSION DISORDER
Examples include
paralysis,
Aphonia(loss of voice)
seizures,
coordination disturbance,
difficulty swallowing,
blindness,
deafness,
double vision,
 Anosmia(inability to perceive smell/odor)
 loss of pain sensation.
Pseudocyesis (false pregnancy) is a conversion symptom
and may represent a strong desire to be pregnant.
 F44
CONVERSION DISORDER

Psychological factors like stress and conflicts are

associated with onset or exacerbation of the symptoms

Emotional conflicts is converted into physical

problems.

Patients are unaware of the psychological basis and are

thus not able to control their symptoms.
 F44 CONVERSION DISORDER
Some features of the disorder include:
• symptom occurs after a situation that produces extreme
psychological stress for the individual.

• Patient does not produce the symptoms intentionally .

• Patient shows less distress or lack of concern about the

symptoms - gives clue to the physician that the problem may
be psychological rather than physical.

• Physical examination and investigations do not reveal any

medical or neurological abnormalities.
 May present symptoms in a dramatic fashion

 Conversion disorders were formerly called as 'hysteria.’

 The term is now changed to conversion Disorder.

 EPIDEMIOLOGY

More common in:

rural populations
lower SES
women than men

Onset: late childhood through early

adulthood;
 CAUSES:
Biochemical influence
 Disturbance in norepinephrine, serotonin level etc.

Psychodynamic Theory
 In conversion disorder, the defense mechanisms involved are
repression.

 Repression(Subconsciously blocking ideas or impulses that are

undesirable) e.g. A child, who faced abuse by a parent, later
has no memory of the events but has trouble forming
relationships

 Conversion symptoms allow a hidden wish or urge to be partly

expressed.

 The symptoms are symbolically related to the conflict.

 CAUSES:

Behavior Theory
 According to this theory the
symptoms are learnt from the
surrounding environment.

 These symptoms bring about

psychological relief by avoidance of
stress.

 Conversion disorder is more common

in people with hystrionic personality
traits.
 CAUSES:

Others factors:
 Repeated trauma

 Stressful life events

 Gains associated with sick role: decreased

responsibility and increased attention

 Stimulant drug abuse.

 Common in lower socioeconomic groups, rural

population and less educated clients.

 CLINICAL FEATURES

Symptoms : very sudden and follows a stressful

experience.

Unintentionally produce symptoms.

Physical examination and investigation do not revel

any medical or neurological condition.
 CLINICAL FEATURES

 Symptoms include:
loss of one or more bodily function
Paralysis
Inability to speak
 seizures,
 coordination disturbance,
 difficulty swallowing,
 urinary retention,
 blindness,
 deafness,
 double vision,
 anosmia
 Pseudocyesis (false pregnancy)

The loss of physical function is involuntary and does not show

any physical cause for dysfunction.
 CLINICAL FEATURES

Patient are motionless and mute and do not respond to

stimulation but they are aware of the surroundings.

Pseudo seizures( Dissociative convulsion) :

Characterized by convulsive movements and partial
loss of consciousness.
 F44 Conversion Disorder
Diagnostic Criteria

A. One or more Sign or deficits affecting voluntary motor or

sensory functioning and indicative of a neurological or other
medical condition.

B. Psychological factors are associated with the deficit the

initiation or exacerbation is preceded by conflicts or stressors.

C. The Sign is not intentionally produced.

 Diagnostic Criteria
A. The Sign cannot be fully explained by a general
medical condition, the effects of a substance, or a
culturally sanctioned behavior or experience

B. Sign cause significant distress or impairment in

functioning or warrant medical attention

C. The Sign is not better accounted for by another mental

disorder
 Diagnosis
History collection
Physical Examination
Mental status examination
Complete Medical workup to rule out medical
problems.
ICD 10 criteria
 MANAGEMENT
Psychological Intervention
 Verbalization of feelings

 Individual psychotherapy:
Free Association :
 refers to the verbalization of thoughts as they occur, without
any conscious screening.
 The psychoanalyst searches for patterns in the material that
is verbalized and in the areas that are unconsciously avoided
(such areas are identified as resistances).
 MANAGEMENT
Psychological Intervention
Hypnosis:
 is an artificially induced state
 person is relaxed
 can be induced in many ways,
using a fixed point for attention,
rhythmic monotonous instructions, etc.

 person highly suggestible to the commands of the hypnotist.

 ability to produce or remove symptoms or perceptions.

 Dissociation(disconnection) of a emotions.

 Amnesia for the events that occurred during the hypnotic state
 MANAGEMENT
Psychological Intervention
Abreaction therapy
 process by which a painful experience or conflict is brought back to
consciousness.

 not only recalls but also relives the material, accompanied by the appropriate
emotional response.

 useful in acute neurotic conditions caused by extreme stress

 procedure is begun with neutral topics at first, and gradually approaches

areas of conflict.

 can be done with or without the use of medication

 MANAGEMENT
Psychological Intervention
Abreaction therapy

 can be facilitated by giving a sedative drug intravenously.

 Safe method is the use of thiopentone sodium i.e. 500 mg dissolved in 10 cc

of normal saline.

 It is infused at a rate no faster than 1 cc/minute to prevent sleep as well as

respiratory depression.
 MANAGEMENT
Psychological Intervention
 Group therapy

 Family therapy

 Supportive psychotherapy
Ventilation
Environmental modification/manipulation
Reeducation
Reassurance

 Meditation and yoga may reduce stress or emotional reaction to

the events.
 MANAGEMENT
Pharmacological Intervention
 Drug therapy: Drugs have a very limited role. A few
patients have anxiety and may need short-term treatment
with benzodiazepines
 Antidepressant drug appear to be more effective
 Nursing Assessment

Presence of physical symptoms with no

pathophysiology
Level of concern regarding physical symptoms
Degree of impairment
Level of anxiety
 Nursing Diagnosis
Disturbed Thought Processes RELATED TO: Severe
psychological stress and repression of anxiety

Ineffective Coping RELATED TO: Severe

psychosocial stressor or severe anxiety

Disturbed Personal Identity RELATED TO: Childhood

trauma/abuse
 Nursing Intervention
 Monitor physician's ongoing assessments, laboratory reports
and other data to rule out organic pathology.

 Do not focus on the disability; encourage patient to perform

self-care activities as independently as possible. Intervene
only when patient requires assistance.

 Positive reinforcement for identification or demonstration of

alternative adaptive coping strategies.
 Nursing Intervention
 Identify specific conflicts that remain unresolved and assist
patient to identify possible solutions.

 Assist the patient to set realistic goals for the future.

 Help the patient to identify areas of life situation that are not
within his ability to control.

 Encourage verbalization of feelings.

 Nursing Intervention

 Do not allow the patient to use the disability as a manipulative

tool to avoid participation in the therapeutic activities.

 Withdraw attention if the patient continues to focus on

physical limitations.

 Encourage patient to verbalize fears and anxieties

 Nursing Intervention

 Provide information to patient ad family that physical

symptoms can be because of stress and internal conflict and can
be managed if stress is resolved.

 Reassure family that she is not seriously physically ill.

 Provide health teaching to family.

Daily healthy routine
Adequate rest and exercise
Proper Nutrition
Relationship of stress and physical symptoms
Educate about relaxaion technique
Decrease attention while patient is on sick role.
 DISSOCTIAVE DISORDER
 Dissociative disorder is the stress related disorder
characterized by disturbance in normally integrated
functions of consciousness, identity or memory.

 Example include motor disturbances, loss of memory, loss

of personal identity etc.

 Results due to lack of ability to cope with realities of

traumatic event

 Often interfere with personal ability to function in daily life.

 DISSOCTIAVE DISORDER
 Rare in general population but prevalent among person
with history of childhood physical and sexual abuse.

 Sudden onset and usually temporary

 Relationship between stress and onset of illness.

 Physical examination and investigation do not reveal any

abnormalities.
 ETIOLOGY
Genetics
 more common in first-degree relatives of people with the
disorder than in the general population.

Neurobiological
 a possible correlation between neurological alterations and
dissociative disorder.
 Areas of the brain that have been associated with memory
include the hippocampus, amygdala, fornix, mammillary
bodies, thalamus, and frontal cortex.
 ETIOLOGY
Psychodynamic Theory
 Freud (1962) believed that dissociative behaviors
occurred when individuals repressed distressing mental
contents from conscious awareness

Psychological Trauma
traumatic experiences like severe physical, sexual, or
psychological abuse by a parent or significant other in
the child’s life.
 ETIOLOGY
Others:
Stress of war or natural disaster
Long term physical, sexual or emotional abuse during
childhood are at greatest risk.
TYPES OF DISSOCTIAVE
DISORDER
 Dissociative Amnesia
Amnesia: loss of memory or the inability to recall.

one or more episodes of the inability to recall important

personal information that is beyond ordinary
forgetfulness.

Patients are sometimes found by the police wandering

aimlessly and are confused and disoriented.

The symptoms cause clinically significant distress or

impairment in social, occupational, or other important
areas of functioning
 Dissociative Fugue
Sudden, unexpected travel away from home or some other
location with the assumption of a new identity (partial or
complete) or a confusion about one’s identity.

The travel and behavior appears normal to casual observers;

thus, the person does not seem to be wandering in a
confused state.

May last from a few hours to several days.

Rare usually follows severe psychosocial stress, such as
marital quarrels, personal rejections, military conflict,
natural disaster, financial difficulty.

Major depression often present prior to dissociative

fugue and there might be a history of childhood trauma.
 DISSOCIATIVE MOTOR DISORDER

Characterize by motor disturbances like paralysis

[ monoplegia , paraplegia or abnormal movements] or
other difficulty with walking.
 DISSOCIATIVE STUPOR

Patient are motionless and mute and do not respond to

stimulation but they are aware of the surroundings.
 DISSOCIATIVE CONVULSION

characterized by convulsive movements and partial

loss of consciousness
TRANCE AND POSSESSION DISORDER

characterized by temporary loss of both the sense of

personal identity and awareness of the person’s
surrounding. When the condition is induced by
religious rituals, the person may feel taken away by
spirit.
 Dissociative Identity Disorder (Multiple
Personality Disorder)

Existence of two or more identities or personalities that

take control of the person’s behavior.

Person or host, is unaware of the other personalities

(alters), but the other alters might be aware of each other to
varying degrees.

May experience memory problems, depersonalization,

identity confusion.
 DIAGNOSIS
History talking
Physical examination
Investigation to rue out medical problems
Mental status examination
ICD 10 criteria
 TREATMENT

1. Psychotherapy
Behavioural therapy
Ignoring: Patient have attention seeking behaviors so less focus should
be provided by ignoring.

Abreaction

Supportive psychotherapy
Ventilation
Environmental modification
Reeducation
Reassurance

family therapy
Marital therapy
Psychoanalysis
2. Drug treatment: The symptoms of anxiety
and/or depression usually respond to short-term
use of benzodiazepines and antidepressants.
 NURSING MANAGEMENT
NURSING ASSESSMENT

History of trauma or abuse

Nightmare and flashback of traumatic event
Low self esteem
Difficult in sleeping
Suicidal tendency
 NURSING MANAGEMENT
NURSING DIAGNOSIS
 Disturbed Thought Processes RELATED TO: Severe psychological stress and
repression of anxiety

 Ineffective Coping RELATED TO: Severe psychosocial stressor or severe

anxiety

 Disturbed Personal Identity RELATED TO: Childhood trauma/abuse

 Disturbed in interpersonal relationship related to low self-esteem and

difficulty expressing feelings.

 Decrease ability to deal with stress related to feelings of helplessness.

 NURSING MANAGEMENT
NURSING INTERVENTION
 Obtain as much information as possible about the client from family and
significant others.

 Consider likes, dislikes, important people, activities, music, and pets.

 Do not ask client with data regarding his or her past life.

 Expose client to stimuli that represent pleasant experiences from the past such
as music known to have been pleasurable to the client.

 Encourage client to discuss situations that have been especially stressful and to
explore the feelings associated with those times.

 Identify specific conflicts that remain unresolved, and assist client to identify
possible solutions. More adaptive ways to respond to anxiety
NURSING INTERVENTION

Reassure client of safety and security through your presence.

Dissociative behaviors may be frightening to the client.

Identify stressor that precipitated severe anxiety.

Help client understand that the disequilibrium felt is

acceptable in times of severe stress.

 As anxiety level decreases and memory returns, an

accepting, nonthreatening environment to encourage client to
identify traumatic experiences.
NURSING INTERVENTION

 Help client define more adaptive coping strategies.

 Examine benefits and consequences of each alternative.

 Provide positive reinforcement for client’s attempts to change.

 The nurse must develop a trusting relationship with the original

personality and with each of the subpersonalities.

 Help client understand the existence of the subpersonalities and the need
for each personal identity of the individual.

 Help client identify stressful situations that precipitate transition from

one personality to another. Carefully observe and record these
transitions.
NURSING INTERVENTION
 Provide support and encouragement during times of
depersonalization.

 Explain the depersonalization behaviors and the purpose they

usually serve for the client.

 Explain the relationship between severe anxiety and

depersonalization behaviors.

 Help relate these behaviors to times of severe psychological

stress that client has experienced.

 Explore past experiences and possibly repressed painful

situations, such as trauma or abuse
NURSING INTERVENTION

 Discuss ways the client may more adaptively respond to stress,

and use role-play to practice using these new methods
Thank you