Nursing management of patient with neurotic disorder. i.e. conversion and dissociative disorder

1. Nursing Management of
Patient with Neurotic, Stress
Related and Somatization
Disorders

2. Neurotic disorder (neurosis) is a less severe
form of psychiatric disorder where, patients
show either excessive or prolonged emotional
reaction to any given stress
Not caused by organic disease of the brain
and however severe, do not involve
hallucinations

3. Psychosis Neurosis
Etiology
Genetic factors
Stressful life events
-More important
-Less important
-Less important
-More important
Clinical features
Disturbances of
thinking &
perception
Disturbances in
cognitive function
Behavior
Judgement
Insight
Reality testing
-Common
-Common
-Markedly affected
-Impaired
-Lost
-Lost
-Rare
-Rare
-Not affected
-Intact
-Present
-Present

4. Treatment
Drugs
ECT
Psychotherapy
-Major
tranquilizers
-Very useful
-Not much useful
-Minor tranquilizers
-Not useful
-Very useful
Prognosis -Difficult to treat
-Relapses are
common
-Complete recovery
may not be
possible
-Relatively easy to
treat
-Relapses are
uncommon
-Complete recovery
is possible

5. F40-F49- Neurotic, stress-related and
somatoform disorders
F40 Phobic anxiety disorders
F41 Other anxiety disorders
F42 Obsessive-compulsive disorder
F43 Reaction to severe stress, and
adjustment disorders
F44 Dissociative (conversion) disorders
F45 Somatoform disorders
F48 Other neurotic disorders

6. DISSOCIATIVE
(CONVERSION)
DISORDERS
PRESENTED BY:
MR. VISHAL SHIVAJI THUBE,
ASSISTANT PROFESSOR,
JCN

7. Conversion disorder is characterized by
the presence of one or more symptoms
suggesting the presence of neurological
disorder that cannot be explained by any
known neurological or medical disorder.
In ICD10, conversion disorder is
subsumed under “dissociative disorders
of movement and sensation”, a subtype
under dissociate disorders.

8.  Studies have estimated that 20%–25% of patients
in a general hospital setting have individual
symptoms of conversion and 5% of patients in
this setting meet the criteria for the full syndrome.
 Dissociative identity disorder statistics vary but
show that the condition occurs in anywhere from
one-half percent to two percent of the population.
... Available research indicates that approximately
two percent of people in the world
experience dissociative disorders and they are
more commonly diagnosed in women.

9. 1. Psychodynamic Theory
 The ego defense mechanisms
involved are repression,
dissociation and conversion
 Conversion symptoms allow a
forbidden wish or urge to be
partly expressed but
sufficiently disguised so that
the individual does not have to
face the unacceptable wish
 The symptoms are
symbolically related to the
conflict

10. 2. Behavior Theory
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

11. Dissociative Motor Disorders
Dissociative Convulsions (hysterical fits or
pseudo-seizures)
Dissociative Sensory Loss and Anesthesia

12. It is characterized by motor
disturbances by like paralysis or
abnormal movements
Paralysis may be a monoplegia,
paraplegia or quadriplegia
The abnormal movement may
be tremors, choreiform
movements or gait disturbances
which increase when attention is
directed towards them
Examination reveals normal tone
and reflexes

13. It is characterized by convulsive
movements and partial loss of
consciousness

14. It is characterized by sensory
disturbances like
hemianesthesia, blindness,
deafness and glove and stocking
anesthesia (absence of
sensations at wrists and ankles)
The disturbance is usually based
on patient’s knowledge of that
particular illness whose
symptoms are produced
A detailed symptoms does not
reveal any abnormalities

15. 1. The symptoms are produced because they
reduce the anxiety of the patient by keeping
the psychological conflict out of conscious
awareness, a process called primary gain.
2. These symptoms of conversion are often
advantageous to the patient called secondary
gain.
3. The patient does not produce the symptoms
intentionally.
4. The patient shows less distress or shows lack
of concern about the symptoms, called as la
belle indifference.

16. 5. Physical examination and investigations do
not reveal any medical or neurological
abnormalities.
6. Lack of conscious control over the
symptoms.
7. Impaired functioning in social work related
areas caused by symptoms.
8. Functioning ability and symptoms
inconsistent with usual neurological
disorders.

17. Dissociation is the mechanism that allows our
mind to separate certain memories from
conscious awareness.
The dissociative disorders are described as a
disturbance in the ordinarily organized
functions of the conscious awareness, memory
and identity.

18. 1. Disturbance in the normal integrative functions of
consciousness, identity and or memory.
2. The disturbance may be sudden or gradual, and the
disturbance is usually temporary, recovery is often
abrupt
3. These disorders tend to occur in response to severe
trauma or abuse. A frequent stressful situation is an
ongoing war.
4. Significant impairment in general and social
functioning.
5. Detailed physical examination and investigations do
not reveal any abnormality that can explain the
symptoms adequately

19. COMMON CLINICAL TYPES
Dissociative
Amnesia
Dissociative
Fugue
Dissociative
Identity
Disorder
Trance and
Possession
Disorders
Other
Dissociative
Disorders

20.  Dissociative amnesia follows a
traumatic or stressful life
situation
 There is a sudden inability to
recall important personal
information particularly
concerning the stressful life
event
 The extent of the disturbance is
too great to be explained by
ordinary forgetfulness
 The amnesia may be localized,
generalized, selective or
continuing in nature

21.  Psychogenic fugue is a sudden,
unexpected travel away from
home or workplace, with the
assumption of a new identity
and an inability to recall the
past
 The onset is sudden, often in
the presence of severe stress
 Following recovery there is no
recollection of the events that
took place during the fugue
 The course is typically a few
hours to days and sometimes
months

22.  In this disorder, the person is dominated by two or more
personalities of which only one is manifest at a time
 Usually one personality is not aware of the existence of the
other personalities
 Each personality has a full range of higher mental functions
and performs complex behavior patterns
 Transition from one personality to another is sudden, and the
behavior usually contrasts strikingly with the patient’s normal
state

23. It is characterized by a temporary loss of both
the sense of personal identity and full
awareness of the person’s surroundings
When the condition is induced by religious
rituals, the person may feel taken over by deity
or spirit

24. The focus of attention
is narrowed to a few
aspects of the
immediate
environment, and there
is often a limited but
repeated set of
movements, postures
and utterances

25.  Ganser’s syndrome (hysterical pseudodementia) is
commonly found in inmates
 The characteristic feature is ‘vorbeireden’ giving
approximate answers to questions
 The term ‘approximate answers’ denotes answers to simple
questions that are plainly wrong, but are clearly related to
the correct answers in a way that suggest that the latter is
known
 Hallucinations are usually visual and may be elaborate

26.  Rule out physical disorders and substance
abuse
 Standard tests including Dissociative
Experiences Scale and the Dissociative
Disorders Interview schedule to
demonstrate presence of dissociation
 ICD 10 criteria and DSM-5 criteria
 According to the DSM-5, conversion
disorder can be diagnosed with symptom
specifiers including the following: weakness
paralysis, abnormal movement, swallowing
symptoms, speech symptoms, attacks or
seizures, anesthesia or sensory loss, or
sensory symptoms

27.  The DSM-5 provides the following criteria to
diagnose dissociative identity disorder: Two or more distinct
identities or personality states are present, each with its own
relatively enduring pattern of perceiving, relating to, and thinking
about the environment and self.
 DSM-V, the symptoms and criteria for dissociative amnesia are
Unable to recall autobiographical memory associated with a
traumatic event. The inability to recall traumatic events creates
distress. The memory dysfunction does not have a physiological
cause.

28. Free association
Hypnosis
Supportive psychotherapy

29. Abreaction therapy
Behavior therapy
Drug therapy

30.  Nursing Assessment: Any physical condition that could
produce the symptoms of amnesia and dissociation must
be ruled out
 Nursing Diagnosis:
- Altered thought process, related to memory loss and
repressed trauma
- Self care deficit related to trance like state or aimless
wandering
- Ineffective individual coping, related to repressed
memories and issues, loss of identity
- Personality identity disturbance, related to childhood
trauma or more than one personality state
- Anxiety, related to repressed traumatic events or loss of
identity

31. The nurse must first establish a trusting and
supportive therapeutic relationship with patient
Use active listening and encouraging
communication techniques for verbalizing feelings,
conflicts and information regarding traumatic events