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The term neurosis is defined as:

  • The presence of a symptom or group of symp­toms which cause subjective distress to the patient.
  • The symptom is recognized as undesirable (i.e. insight is present).
  • The personality and behavior are relatively preserved and not usually grossly disturbed.
  • The contact with reality is preserved.
  • There is an absence of organic causative factors.
  1. Dissociative (conversion) Disorders, Hysteria

    Clinical features:
    Conversion disorder is characterised by the following clinical features :-
    1. Presence of symptoms or deficits affecting motor or sensory function suggesting a medical or neurological disorder.
    2. Sudden onset.
    3. Development of symptoms usually in the presence of a significant psychosocial stressor (s)
    4. A clear temporal relationship between stressor & development or exacerbation of symptoms.
    5. Detailed physical examination do not reveal any abnormality that can explain the symptoms adequately.
    6. Astasia – abasia (Blocq’s disease)  Inability to walk or stand in a normal manner. The Gait is bizarre and is not suggestive of any organic lesion.
    7. “Labella” indifference: no regard for symptoms though look severe i.e. emotions are not matching with loss.
      Labella - is a french word meaning emotion. i.e emotions are not matching with the loss.
      e.g somebody smilingly coming to doctor with Complaints of Blindness.
Common Presentations of Conversion Disorder
  • Dissociative anaesthesia and sensory loss - patient presents with sensory loss which is not substantiated on physical examination.
  • Dissociative motor disorder— loss of ability to move limb / in coordination etc.
  • Dissociative convulsions: Usually in presence of family members / friends, no injuries/frothing incontinence, last more than 1 min, not stereotyped, never in sleep.
There are 2 types of Gains described for Dissociative Disorder
  1. Primary Gain - Relief from Unconscious signal Anxiety.
  2. Secondary Gain - Observable Gain or some benefit is called as secondary Gain. 
Table : Dissociative Convulsions And Epileptic Seizures
Clinical Points Epileptic Seizures Dissociative Convulsions (‘Hysterical
Attack pattern Stereotyped, known clinical pattern Absence of any established clinical patterns Purposive body movements occur.
Place of occurrence Anywhere Usually indoors or at safe places
Warning Both prodrome & aura are stereotyped Variable
Time of day Anytime Can occur during Sleep Never occur during sleep
Tongue bite Usually present Usually absent cheek and lip bite may be present
Incontinence of urine and feces Can occur Very rare
Injury Can occur Very rare. If occur, it is minor or may be accidental
Speech No verbalization during the seizure during the fit. Verbalization may occur during the fit
Duration Usually about 30-70 sec. (Short) 20-800 sec (prolonged)
Head turning Unilateral Side to side turning
Eye gaze Staring, if eyes are open Avoidant gaze
Amnesia Complete Partial
Neurological Present, e.g. up going planters          Absent
Post-ictal confusion Present Absent
Stress Present in 25% Present much more often
EEG- Inter-ictal-Ictal Usually abnormal Usually Normal
Serum prolactin Increased in post-ictal period (15-20 minutes after seizure; returns back to normal in 1hour) Usually normal

Seizures in night indicate organic pathology
In Conversion disorder:
  1. The symptoms focus on deficits that involve motor or sensory function and on psychological factors that initiate or exacerbate the medical presentation.
  2. Like somatization disorder, the deficit is not intentionally produced or simulated, as is the case in factitious disorder (malingering). 
  1. Special Types of Dissociative Disorder

    1. Dissociative amnesia — loss of memory c is too extensive to be explained by ordinary forgetfulness.
Types of Dissociative Amnesia
  1. Circumscribed Amnesia (commonest type):
  2. There is an inability to recall all the personal events during circumscribed period of time, usually corresponding with the presence of the stressor.
  3. Selective Amnesia (less common):
  4. This is similar to circumscribed amnesia but there is an inability to recall only some selective personal events during that period while some other events during the same period may be recalled.
  5. Continuous Amnesia (rare):
  6. In this type, there is an inability to recall all personal events following the stressful event, till the present time.
  7. Generalized Amnesia (very rare):
  8. In this type, there is an inability to recall the personal events of the whole life, in the face of a stressful life event.
  1. Dissociative fugue — Dissociative amnesia + purposeful travel beyond the usual everyday range + maintenance of basic self care & other functions.
  2. Multiple personality disorders/dissociative identity disorder.
  3. Ganser syndrome— Approximate answers, also in German language called as ‘Vorbeireden’
  4. Depersonalization — “As If” phenomenon about the self. Person feels ‘as if’ & something in him has changed.
  5. Derealization — ‘as if’ phenomenon about the environment. ‘As if’things in surrounding have charged.
Treatment: Insight oriented psychotherapy with abreaction / behavior therapy.
  1. Somatoform Disorders
    In this category the patients presents with somatic symptoms for which there is no existing signs or no existing pathology.
Somatization disorders – (earlier called as Briquet’s syndrome)
  1. In this disorder the patients presents with multiple somatic complaints at least 6+ 1(pseudo neurological) of 4 systems of the body for 2 years.
  2. In Somatization there is a Doctor Shopping , Patient had multiple Investigations,
  3. But “To Know the Diagnosis “
    1. The patient presents with multiple physical complaints referable to different organ systems.
    2. Onset is usually before age 30, and the disorder is persistent.
    3. Formal diagnostic criteria require the recording of at least four pain, two gastrointestinal, one sexual, and one pseudo neurologic symptom.
    4. Patients with somatization disorder often present with dramatic complaints, but the complaints are inconsistent.
    5. Symptoms of comorbid anxiety and mood disorder are common and may be the result of drug interactions due to regimens initiated independently by different physicians.
    6. Patients with somatization disorder may be impulsive and demanding and frequently qualify for a formal comorbid psychiatric diagnosis.
  1. Normal physiological or minimal pathological symptoms are taken as a sign of deadly disease. eg. Person hearing 1-2 bowel sound /day (which is normal) with distension & minimal constipation believes that he is having carcinoma colon.
  2. In Hypochondriasis - There is Doctor Shopping , Patient had multiple Investigators,
  3. But “To Confirm the Diagnosis “
    1. The essential feature is a belief of serious medical illness that persists despite reassurance and appropriate medical evaluation.
    2. As with somatization disorder, patients with hypochondriasis have a history of poor relationships with physicians stemming from their sense that they have been evaluated and treated inappropriately or inadequately.
    3. Hypochondriasis can be disabling in intensity and is persistent, with waxing and waning symptomatology.
Body dysmorphic disorder:
  1. There is persistent “doubt” about the appearance of body Person “doubts” that the nose is “ugly”, “too long”.
  2. In body dysmorphic delusion (a type of somatic delusion), Person has “fixed” belief that nose is ugly and hiding nose & requesting surgeons to operate the nose, is present.
  3. But the difference is very minute between the two disorders so question should be read very carefully.
  4. Body Dysmorphic Disorder is very close to Obsessive Compulsive disorder phenomenological, because in this also, there is repetitive doubts, Infact, Body Dysmorphic Disorder is a spectrum Disorder of OCD.
  1. Factitious Disorder
    1. Munchausen’s syndrome or Munchausen’s syndrome by proxy (also known variously as Hospital Addiction, Hospital Hoboes, or Professional Patients, Doctor shopping) is used for those patients who repeatedly simulate or fake diseases for the sole purpose of obtaining medical attention.
    2. There is no other recognisable motive (hence, it is different from malingering).
    3. The patients distort their clinical histories, laboratory tests’ reports, and even facts about other aspects of their lives (pseudologia fantastica).
    4. Sometimes, they distort physical signs by self-inflicted injuries and secondary infections. Drug abuse, especially abuse of prescription drugs, is common.
    5.  Evidence of earlier treatment, usually surgical procedures, is often available in the form of multiple scars (e.g. “grid-iron abdomen”).
    6. These patients are often manipulative and convincingly tell lies, create problems in the inpatient setting and often leave against medical advice, usually after the surgical procedure has been performed.
    7. In this disorder the gain is primary gain i.e. the patients get unconscious pleasure in company of doctors.

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