19.10 Dissociative Disorders.
Care Needs and Mobility Considerations
(i) In dissociative and conversion disorders the predominant symptoms are physical . The term conversion disorder implies that in the affected person anxiety has been replaced by (or "converted into") physical symptoms. It is assumed that the physical symptoms serve a function in that they enable the affected individual to avoid situations with which they cannot cope. These disorders are also forms of neurosis; but in view of their importance and the critically important need to differentiate them from malingering where an apparent disability is out of proportion to the physical condition,this separate section is devoted to them and related disorders.
(ii) An alternative name for these disorders is hysteria. Although this term is still in use, many psychiatrists avoid it because colloquially it is used to describe exaggerated and extravagant displays of emotion. This is not the meaning of hysteria when used in the clinical context.
(iii) Somatoform or Somatization disorder is a type of conversion disorder. It is used to denote a chronic condition characterised by a history of numerous, variable and recurrent physical complaints that may begin in early life and persist for many years. These physical symptoms are not accounted for by physical disease. In one form of the disorder there are complaints of chronic pain which cannot be explained by any primary physical or mental disorder.
(iv) A dissociative (or conversion) symptom suggests physical illness but occurs in the absence of relevant physical findings and any evidence of physical disease. The symptom arises from unconscious psychological mechanisms.
(v) A definite diagnosis of a dissociative (or conversion) disorder made by a consultant psychiatrist implies that attempts have already been made to ensure that as far as possible underlying relevant physical disease has been excluded.
(vi) In reaching that diagnosis the psychiatrist also has to be satisfied that the symptoms arise unconsciously rather than consciously and deliberately. The deliberate feigning of symptoms is known as malingering and this is dealt with separately at paragraph 19.11.
(i) Although dissociative and conversion symptoms are produced unconsciously they are shaped, in the individual person, by that person's knowledge and understanding of illness. Usually there are discrepancies between the signs (clinical findings) and symptoms (what the person complains of) and those of an identifiable specific disease. For example, a report of a medical examination may reveal a pattern of loss of sensation in a part of the body that does not correspond to the way in which that part of the body is supplied by nerves which carry the feeling of sensation to touch, etc.
(ii) Secondary gain is a term which is sometimes used in medical reports on people with dissociative disorders. This means that the symptom confers some immediate advantage on the affected individual. An example of secondary gain is the advantage that conversion disorder which manifests as, say, paralysis of the legs, might bring by relieving the person from the stressful care of a relative with severe disabilities.
(iii) The manifestations of these dissociative disorders are many, ranging from muscle paralysis and unusual patterns of walking (disorders of gait) through convulsions to apparent blindness or deafness and the complaint of chronic pain
(iv) Psychogenic is another word which may be used to describe a symptom of a dissociative or conversion disorder.
(v) People with somatization disorder have multiple complaints over long periods. They may consult many doctors throughout life. Associated depressive and anxiety symptoms are common.
(vi) Hypochondriacal disorder is a persistent preoccupation with the possibility of having a serious illness. Frequently, people with this disorder attach major significance to even minor symptoms
(vii) Adopting the "sick role" or the "patient role" also appears sometimes in medical reports. They are not very helpful because they may indicate that the person has a dissociative (conversion) disorder or that the role has been adopted as a matter of choice. "Illness behaviour" is a common response to a situation which is perceived as an intolerable predicament. The advice of a Medical Services doctor should help to clarify the situation.
(viii) Functional Overlay is another term which may be found in medical reports. This is usually interpreted as unconscious exaggeration or elaboration of symptoms for which there is an organic basis. However it may be used by some doctors to indicate an element of conscious exaggeration too. When it appears in reports Adjudication Officers are advised to seek advice from a Medical Services doctor for interpretation of its meaning in the particular context.
19.9.3 Care Needs and Mobility Considerations
(i) Most people with dissociative and conversion disorders of recent onset recover quickly (ie within a matter of several months). Those cases that persist for longer than a year are likely to continue for many more years.
(ii) People with dissociative (or conversion) disorders including those with somatization are neither consciously nor deliberately feigning their symptoms. Thus care needs and mobility requirements must be assessed on the same basis as if the manifest disabilities were due to a recognised specific physical disease
(i) It is absolutely essential that a reported diagnosis of dissociative or conversion disorder, hysteria or somatization is confirmed by obtaining a factual report from a hospital attended by the person or from a doctor or community psychiatric nurse in the psychiatric services involved with the person.
(ii) Sometimes a report from an examining medical practitioner or a factual report from the GP will mention a diagnosis of somatization, hysteria or dissociative/conversion disorder, or use the term psychogenic. In these circumstances, and in the absence of any documented confirmation of the diagnosis by a consultant psychiatrist, advice should be sought from a Medical Services doctor on the most appropriate source of further evidence to confirm or refute the diagnosis and to establish the nature and extent of the resultant disabilities.