Transcript Chapter 10：Conversion and dissociation
Chapter 10 Conversion and dissociation
Zhonghua Su Jining Medical University
Main elements
they lack evidence of proximate organic illness or pathophysiological disturbance; the symptoms correspond to ideas of the patient about how parts of the body or mind malfunction or fail to function.
The most representative examples ： blindness, deafness, paralysis, loss of speech, and certain types of memory disturbance, including fugue states. global memory loss.
Neither are they due to delusions or hallucinations as conventionally defined.
History
2000 前，的埃及记载： hysteria 为子宫之意； 希腊历史学家 Herodote 和医学家 Hippocrates 的类似看法； 1618 年， Charles Lepois ：癔症在脑而非子宫； 1859 年， Briquet 综合征（ 430 cases ）； 1886 年， Charcot 提出癔症可为催眠引起或消除，遗传有关； 1885 年， Freud ，《癔症的研究》 1898 年， Ganser 描述了 Ganser 综合征、假性痴呆和童样痴 呆 1950’s ，癔症误诊精神分裂症、心境障碍、人格障碍、酒 精中毒、药物依赖、焦虑症
History
The recognition of the relevance of emotion and motive to bodily and mental symptoms is as old as Hippocrates and Galen.
Reynolds and Charcot recognized that hysteria depended upon an idea, but the way in which the idea works is another matter.
At the start of the First World War the conditions that we now call conversion and dissociative disorders were common.
The original Freudian theory suggested that ideas which were completely absent from the patient's memory in a normal state, or present only in ‘a highly summary form', could be revealed by hypnosis.
Current meaning
hysterical symptoms arose from the conversion of emotional energy to a physical symptom unconscious motives and emotional conflict a split in mental processes a disruption in the integrated
Epidemiology (1)
22 /100,000 5 -15% of psychiatric consultations in a general hospital 25-30% percent of admissions to a Veterans Administration hospital Woman: Men 2 :1 or 5 :1 onset at any time most common among rural populations commonly associated with comorbid diagnoses of major depressive disorder, anxiety disorders, and schizophrenia.
Epidemiology (2)
Dissociative amnesia most common dissociative symptom; occurs in almost all the dissociative disorders; occur more often in women than in men and more often in young adults than in older adults; usually associated with stressful and traumatic events; Dissociative fugue is rare Dissociative Identity Disorder transient depersonalization
诊断分类
癔症
(40)
、应激相关障碍、神经症 （
CCMD
－
3
）
癔症性精神障碍 40.1
癔症性躯体障碍 40.2
癔症性躯体－精神障碍 40.3
其他或待分类的癔症 40.9
Ganser’s 综合征 40.91
见于儿童和青少年短暂的癔症性障碍
癔症性精神障碍 40.1
癔症性遗忘 癔症性漫游 40.11
40.12
癔症性身份识别障碍 癔症性木僵 40.13
癔症性精神病 癔症性附体障碍 与文化相关的癔症性附体障碍 40.14
癔症性感觉障碍 癔症性运动障碍 癔症性抽搐发作 癔症性感觉障碍 40.2
40.21
40.22
40.23
40.141
40.142
40.1411
分离（转换）性障碍（
F44
） （
ICD
－
10
）
分离性遗忘 分离性漫游 分离性木僵 出神与附体障碍 分离性运动障碍 分离性抽搐 分离性感觉麻木和感觉丧失 混合性分离（转换）性障碍 其它分离（转换）性障碍 分离（转换）性障碍，未特定 F44.0
F44.1
F44.2
F44.3
F44.4
F44.5
F44.6
F44.7
F44.8
F44.9
DSM
－
IV
躯体形式障碍
300.81
躯体化障碍 300.81
未分化的躯体形式 障碍 躯体变形障碍
300.11
转换障碍 307.XX
疼痛障碍 疑病症 未加标明的躯体形式障碍
分离性障碍
300.12
分离性遗忘症 300.13
分离性神游症 300.14
分离性身份障碍 300.6 人格解体障碍 300.15
未加表明的分离性 障碍
转换障碍（
DSM
－
IV
）
A.
B.
C.
D.
E.
F.
影响着自主运动或感觉功能，并提示是一种神经系或其他一般躯体 情况的一种以上症状。 可以判断有心理因素伴随于这些症状或缺陷，因为在症状的发生或 恶化之前都有心理冲突或其他应激。 这些症状或缺陷都不是有意识地产生或伪装的（如人为性障碍或诈 病）。 在适当的调查了解后，可以发现这些症状或缺陷不可能用一般躯体 情况或某种物质的直接效应来解释的，也不象其文化所认可的行为 或体验。 这些症状或缺陷产生了临床上明显的痛苦烦恼或在社交、职业、或 其他重要方面的功能缺损，或者要找内外科作出评价保证。 这些症状缺陷不限于疼痛或性功能失调，可以排除是在躯体化障碍 中发生的，也不可能归于其他精神障碍。 标明：具有运动症状或缺损 具有感觉症状或缺损 具有癫痫发作或抽搐 具有混合的表现
神经症
40
恐怖性神经症 40.0
焦虑性神经症 40.1
强迫性神经症 40.2
抑郁性神经症 40.3
癔症
40.4
神经衰弱 40.5
其它神经症 40.8
DSM
－
2
－
R
癔症
40.4
癔症性遗忘 40.40
癔症性漫游 40.41
癔症性身份识别障碍 40.42
癔症性精神病 癔症性转换障碍 40.44
其它癔症性障碍 40.48
如 Ganser’s 综合征 未特定性癔症 40.49
Clinical features
Conversion disorder
Sensory Symptoms
感觉过敏或缺乏 视觉、听觉障碍 癔症球 植物神经和内脏功能障碍 心因性疼痛
Motor Symptoms
癔症性失音 癔症性瘫痪 起立不能、运动不能 肢体震颤、抽动和肌阵挛
Seizure Symptoms
Dissociative disorder
Stupor Amnesia Fugue Dissociative identity disorder
Recovered Memory Syndrome
Ganser's Syndrome
情感爆发 意识朦胧状态 恍惚状态和附体状态 癔症性精神病
Sensory symptoms
Anesthesia and paresthesia are common, especially of the extremities.
Distribution of the disturbance is in consistent Characteristic anesthesia: stocking-and-glove anesthesia of the hands or feet the hemianesthesia of the body organs of special sense: deafness, blindness, and tunnel vision.
be unilateral or bilateral; walk around without collisions or self-injury pupils react to light is normal their cortical evoked potentials is normal
Motor symptoms
include abnormal movements, gait disturbance, weakness, and paralysis. worsen when attention is called to them. rarely fall; if they do, they are generally not injured. paralysis and paresis involving one, two, or all four limbs Reflexes remain normal; no fasciculations or muscle atrophy electromyography findings are normal.
Seizure Symptoms
最常见大发作（农村 1/2 ，住院患者 1/5 ） 常于情绪激动 / 受到暗示时突然发生 突然跌倒，手足抽动，屏气 / 过度换气，问之不答， 但无意识障碍 发作时： 无强直阵挛 几乎没有咬伤，跌伤，尿失禁 角膜反射良好 无伸性柘反射 发作后，无催乳素水平增加
Stupor
常为精神创伤体验所触发 / 发生于精神创伤之后 突然发生的自主运动减少或丧失 在相当长的时间内维持固定的姿势，没有言语和随意 运动； 但是，对光线、声音或疼痛刺激反应正常； 肌张力、姿势和呼吸可无明显异常，眼球向下转动 / 紧 闭双眼； 出现较深的意识障碍，既非入睡，也不是昏迷状态， 10 余分钟自行缓解； 精神分裂症紧张型、抑郁性木僵鉴别
Amnesia
对自己经历的重大事件突然失去记忆，常与精神 创伤有关； 常无脑器质性损害（个别除外）； may not know who he is, but knows who is the Queen, the President, or his doctor.
Unaware of his own personal history, he may yet play chess well, speak one or two languages, read the newspaper, and so forth. 常就诊于神经科 more frequent amongst criminals or soldiers in distress.
B.
C.
A.
分离性遗忘（
DSM
－
IV
）
The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
The disturbance does not occur exclusively as a symptom of dissociative identity disorder, dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder and is not due to the direct physiolgoical effects of a substance (eg, a drug of abuse, a medication) or a neurological or other general medical condition (eg, amnestic disorder due to head trauma).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. A.
B.
C.
明显突出的障碍是：一次以上的发作， 发作时不能回忆重要的个人问题；往 往属于创伤性或应激性质，而且太过 分以致不能用通常的健忘来解释。 这种障碍并非发生于分离性身份障碍、 分离性漫游、创伤后应激障碍、急性 应激障碍、或躯体化精神障碍的病程 之中，也不是由于某种物质（例如滥 用药物、治疗药品），或某种神经系 或其他一般躯体情况，（例如颅脑外 伤所致遗忘性障碍）所致之直接生理 效应。 这些症状产生了临床上明显的痛苦烦 恼、或在社交、职业、或其他重要方 面的功能缺损。
Fugue
突然从家中或单位出走，到外地旅行。地点可能是以往熟 悉或有情感意义的地方。 此时意识范围缩小： 但保持基本生活能力和简单的社会接触交往能力； 外人看不出其言行和外表有明显异常。 历时几十分钟到几天，常突然清醒。 事后难以回忆。 Fugue : organic fugue Fugue : postical states 10 of 25: epilepsy, 1 with schizophrenia, several others had depression (Stengel)
A.
B.
C.
D.
分离性漫游（
DSM
－
IV
）
The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past.
Confusion about personal identity or assumption of a new identity (partial or complete).
The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, temporal lobe epilepsy).
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. A.
B.
C.
D.
突然、出乎意料地离家或离开平常工 作单位出外旅行，而不能回忆自己的 过去。 .
对于个人的身份搞不清楚，或假设了 一种新的身份（部分的或全部的）。 此障碍并非发生于分离住身份障碍的 病程中，也不是由于某种物质（例如， 某种滥用药物，治疗药品）或一般躯 体情况（例如，颇叶癫痫）所致之直 接生理性效应。 这些症状产生了临床上明显的痛苦烦 恼，或在社交、职业、或其他重要方 面的功能缺损。
Dissociative identity disorder
formerly multiple personality disorder 患者突然失去对自己往事的全部记忆，对自己原 来的身份不能识别，以另一种身份进行日常社会 活动。 表现为两种或两种以上明显不同的人格，各有其 记忆、爱好和行为方式，完全独立，交替出现， 互不联系，在某一时刻只是显示其中一种人格， 此时意识不到另一种人格的存在。 初次发病突然，与精神创伤有关；以后发病，可 由联想或特殊生活事件触发。
A.
B.
C.
D.
分离性身份障碍（
DSM
－
IV
）
The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
At least two of these identities or personality states recurrently take control of the person's behavior.
Unability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
The disturbance is not due to the direct physiological effects of a substance (eg, blackouts or chaotic behavior during alcohol intoxication) or a general medical condition (eg, complex partial seizures). A.
B.
C.
D.
存在 2 种以上明显的身份或人格（每一 种都有他自己相对长久的对环境和自 我的认识、关系、或想法）。 至少有 2 种这种身份或人格反复地控制 他的行为。 不能回忆重要的个人问题，而且太广 泛以致不能用通常的健忘来解释。 此障碍不是由于某种物质（例如急性 酒中毒时的黑懵或混乱行为）或一般 躯体情况（例如复合性部分性抽搐） 所致之直接生理性效应。 Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. 注：如是儿童，症状并非由于想像性 的游戏伙伴或其他幻想性游戏。
B.
C.
A.
Conversion Disorder
（
1
）
One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neorological or other GMC Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors The symptom or deficit is not intentionally feigned (as in Factitious Disorder or Malingering) A.
B.
有一种或多种影响随意运动或 感觉功能，并提示为神经系统 或其他躯体情况的症状或缺损； 因为症状或缺损出现或恶化以 前有心理冲突或其他应激因素， 所以可以判断心理因素与这些 症状或缺损有关 C.
这些症状或缺损不是有意制造 或假装的（如在做作性障碍或 诈病时那样）
Conversion Disorder
（
2
）
D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience E. The symptom or deficit causes clinically significant distress or impairment in functioning F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder 经过适当的调查后，这些症状 或缺损不能完全用已知的躯体 情况、物质直接效应或文化认 可的行为或体验来解释 这些症状或缺损引起具有临床 显著意义的苦恼或社交、职业、 其它功能损害，或称为患者就 诊的理由 这些症状或缺损不限于疼痛或 性功能失调，不仅发生与躯体 化障碍的病程中，不能用其他 精神障碍解释。
表明
Specify type of symptom of deficit:
With motor symptom or deficit
With sensory symptom or deficit With seizures or convulsions With mixed presentation
表明 具有运动症状或缺损（如， 共济失调、麻痹或局部无力、 吞咽困难或“喉头有团块” 感、失音、尿潴留） 具有感觉症状或缺损（如触 觉或痛觉丧失、复视、盲、 聋、幻觉） 具有癫痫发作或抽搐（包括 具有随意运动或感觉成份的 癫痫样发作或抽搐） 具有混合性表现
Differential diagnosis
（
1
）
Conversion disorder ruling out a medical disorder.
Neurological disorders dementia and other degenerative diseases brain tumors basal ganglia disease schizophrenia, depressive disorders, and anxiety disorders somatization disorder. somatization disorder hypochondriasis pain disorder sexual dysfunction
Differential diagnosis
（
2
）
Dissociative amnesia
Amnesia associated with dementia and delirium head trauma Epilepsy
Dissociative fugue
dissociative amnesia schizophrenia rapidly cycling bipolar disorders Borderline personality disorder Malingering
Dissociati ve identity disorder
depressive disorders and schizophrenia psychotomimetic drugs
Prognosis
In general the prognosis for symptoms of acute conversion or dissociation is good but that for longer lasting symptoms is relatively poor. The prognosis for monosymptomatic conversion is usually good suicide rate among men was similar to that in the general population, but the rate for women was higher a third of patients had improved at follow-up, a third were unchanged, and a third were worse
心理治疗 暗示治疗 催眠治疗 解释性心理治疗 分析性心理治疗 行为治疗 疏泄治疗 家庭治疗
Treatment
药物和物理治疗 抗精神病药物治疗 抗抑郁药物治疗 抗焦虑药物治疗 针刺或电刺激治疗
Treatment
Most patients with conversion symptoms are managed by general practitioners Symptoms may be minor, short lived, or self-limiting Brief psychotherapy may be helpful intensive psychodynamic psychotherapy is unlikely to be useful