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Byline: Asad Ullah Jan and Salim Jehangir


Objective: To determine the mode of presentation of dissociative disorders presenting at Armed Forces Institute of Mental Health.

Study Design: Cross sectional study.

Place and Duration of Study: The study was conducted at the Armed Forces Institute of Mental Health (AFIMH) Rawalpindi from 1st June 2013 to 31st August 2013.

Patients and Methods: Fifty four patients of dissociative disorders were included in the study by using consecutive non-probability sampling. Category of presentation of dissociative disorders in the participants was determined by the primary mode of presentation and by using international classification of diseases (ICD)-10 diagnostic guidelines.

Results: The commonest type of presentation of dissociative disorders was mutism (40.7%), possession state (18.5%), pseudo fits (12.9%) followed by paraparesis (9.2%).

Conclusion: Predominantly the patients presented with mutism (dissociative motor disorder).

Keywords: Dissociative disorder, mutism, paraparesis.


Dissociative (conversion) disorder is defined as the presence of neurologic symptoms in patients in the absence of any neurologic disorder and the clinical diagnosis does not fully account for all of the patient's symptoms even if a diagnosis of a neurological disorder is present1. In the event of traumatic or stressful situations dissociation provides a psychological protection by detaching the individual from the potentially threatening situation and providing physical analgesia by translating psychological stress into physical symptoms. It may be compared to the reaction of an animal freezing in the face of overwhelming danger when fight or flight is not possible2.

ICD-10 classifies this disorder into dissociative amnesia, dissociative fatigue, dissociative stupor, dissociative disorders of movement and sensation, dissociative motor disorders, dissociative convulsions, dissociative anaesthesia and sensory loss, mixed dissociative [conversion] disorders and other dissociative [conversion] disorders3. The clinical features of dissociative disorders are given in table-I. The prevalence of dissociative disorder is variable. Different studies have shown varying results. However, it has been noted that around 2025% of patients have symptoms of conversion in a general hospital setting and around 5% of patients meet the criteria for the full disorder in these health care settings. This percentage increases in the neurologic settings where about 20% of the patients present with symptoms that cannot be attributed to a neurological diagnosis.

However, in psychiatric services a different figure of life time prevalence of 23/100000 is encountered for the disorder4. There is a general consensus that dissociative disorder is more common in the females and the onset can be at any age across the life span of the affected individual5.The clinical picture and the presentations of dissociative disorder are different in different settings of the Pakistani population keeping in view the socio- cultural background and the local customs6. Keeping in view the variance in the socio- cultural practices of the Pakistani population and lack of studies on this topic in military settings, it was pertinent to carry out a study in military setup on the mode of presentation of patients of dissociative disorder reporting to a tertiary psychiatric care institute in Rawalpindi.


It was a cross-sectional observational study carried out at Armed Forces Institute of Mental Health (AFIMH) Rawalpindi Pakistan for duration of three months from 1st June 2013 to 31st August 2013. Those patients having a diagnosis of medical or surgical illnesses and those not consenting to the study were excluded from the study. Patients of dissociation diagnosed on the basis of ICD-10 diagnostic guidelines were included in the study. Fifty four patients fulfilling the inclusion criteria reported during the study period were included in the study through non probability consecutive sampling. Informed written consent was obtained. Data had been entered and analyzed using SPSS (version 14). Descriptive statistics were used to describe the results.


Out of 54 patients who presented to AFIMH, 21 (38.9%) were male and 33 (61.1%) were female. The mean age of presentation of the patients was 24.6 years. Out of the total 18 (33%) were educated till 10th grade while 10 (18%) were educated till 8th grade. Out of the total, 34 (63%) were single, 19 (35%) were married while 1 (2%) was divorced. As regards employment status 24 (44.4%) were employed while 30 (55.6%) were unemployed. As regarding birth order, 23 (42.5%) of the total were third while 15 (27.7%) were second in the birth order. As regards mode of presentation, 22 (40.7%) presented with mutism, 10 (18.5%) presented with possession state, 7 (12.9%) presented with pseudo fits (fig-1). 31 (57.4%) were having marital or interpersonal conflicts. Eleven (20.3%) were having employment/job related conflicts while conflicts couldn't be identified in 6 (11.1%) of the patients (fig-2).

The symptoms of 52 (96.2%) were resolved with suggestive psychotherapy and supportive therapy while the symptoms of 2 (3.8%) patients couldn't be resolved. The median duration of symptoms was 01 day.

Twenty eight (51.8%) patients did not have a history of past dissociative episode.


Dissociation was known as hysteria and the term dissociative disorder is now used to cover the sensory, motor and mixed manifestations of the now obsolete term, hysteria7. Our study shows that the highest number of patients presented with mutism (40.7%) followed by possession state (18.5%) and pseudo fits (12.9%). Our study investigated the mode of presentation of the patients however, after applying strict ICD-10 criteria for dissociative disorder sub types, our findings show that 18.5% were having trance and possession disorders, 64.8% were having dissociative motor disorders in the form of paraparesis, hemiparesis and mutism, 13% fulfilled the criteria of dissociative convulsions and 3.8% presented with dissociative anaesthesia and sensory loss.

A study conducted at the Institute of Psychiatry, Rawalpindi General Hospital in 2005 showed that the commonest mode of presentation was mixed dissociative disorder (38%) followed by dissociative motor disorder (26%) and the main stress or conflict was from primary support group8. Our findings suggest that most patients presented with motor symptoms followed by trance and possession state and then dissociative convulsions. The main stressor or underlying conflict in our study was interpersonal or marital conflict in 57.4% of the patients followed by job/employment related conflicts in 20.4% of patients. This finding points towards the major role of the interpersonal and marital issues that lead to development of dissociative disorders. The same conclusion was drawn from a recent study conducted at Rawalpindi where majority of the patients reported with difficulties with primary support group including family circumstances9.

The mean duration of the episode could not be ascertained as there were two patients whose symptoms exceeded more than an year for the current episode so median was taken and that was 1 day. Results from a study of patients reporting to a tertiary care psychiatric facility in Abbottabad showed that 35% patients of dissociation presented with the symptoms of pseudoseizures, 16% had symptoms of paralysis, 12% reported with tremors, 13% had aphonia or mutism, 6% each presented with gait disorders and difficulty in swallowing while 4% with blindness and 3% with anaesthesia or sensory loss10. Another study conducted in patients reporting to Pakistan Ordnance Factories (POF) Wah hospital showed that the commonest presentation of dissociative disorders was dissociative anesthesia and sensory loss 38 (38%) followed by dissociative disorder unspecified 30 (30%) with features similar to mania and psychosis11.

This shows the variability in the symptomatic presentation of dissociative disorder across various regions of Pakistan with different socio-cultural background. Risal and Tharoor explored the relationship between birth order and various psychiatric illnesses in Indian population. Their study found that dissociative disorder was more prevalent in the first order child (26.7%), with twice the prevalence in females (57.1%)12. Our study conforms to these findings in terms of the increased frequency of dissociative disorder in the female (61.1%) but the disorder was found to be most prevalent in patients having third birth order (42.6%). Again this might reflect the variability in socio-cultural and economic circumstances of the two population samples.


Considering the above-mentioned clinical presentations of dissociative disorder it is concluded that mutism is the commonest mode of presentation at AFIMH Rawalpindi with marital and interpersonal conflicts as the predominant underlying cause


This study has no conflict of interest to declare by any author.


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Publication:Pakistan Armed Forces Medical Journal
Date:Oct 31, 2015

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