CASE PRESENTATION

ONCONVERSION

DISORDER

DEMOGRAPHIC INFORMATION

•Name: Rayan Khan•Age: 10 Years•Sex: Male•Address: Chandra, Kaliakoir, Gazipur.(Sub-urban)•Siblings: 2•Position: Second•Religion: Islam •Economic status: Middle Class •Educational Qualification : Standard five

SOURCE OF REFERRAL The client was referred to BSMMU

the from local doctor.

CHIEF COMPLAINTS

Stiffness of whole body Inability to flex knee joint Feeling stress and conflict.

HISTORY OF PRESENT ILLNESS

History revealed occasional complaints of body painfor the last 2 months which was being relieved by body massage.One week back the boy complained of body ache and also vomited after having breakfast. He could not attend school that time.He slept for about 2 hours and wake up with stiffness of bodyand developed inability to flex upper and lower limbs. He was

admittedin a hospital, where he regained mobility of the upper limbsbut was not able to bend his knees and walked with a stiffgait. His mother noticed that when the child was asleep hislimbs were not rigid and would be flexed. The followingmorning he was able to walk and run. When discharge wasplanned there was a relapsed of all the symptoms.

FAMILY HISTORY

There was no significant past history of psychiatric orneurological disturbances of the child and his parents. Developmental history was reported to be unremarkable. Family relationships were reported to be cordial.

PERSONAL HISTORY Mother’s pregnancy and birth: During his mother’s

pregnancy there was no serious illness and his birth was normal and no complication held after birth.

Early development: His developmental milestones were normal. According to client’s mother, his childhood was normal and there was no separation, emotional problem during childhood.

Schooling and higher education: He was a good student from his early childhood of time.

HISTORY OF PAST ILLNESS

Past medical illness:Nothing contributory.

  Past psychiatric illness:

Nothing contributory.  

PRE MORBID PERSONALITY

Relationship: Relationship with his own family and friends was good

Leisure activities: He enjoyed with reading books, playing and roaming with friends etc

Prevailing mood: His prevailing mood was cheerful.

Attitudes and standards: He had a good moral standards and normal attitudes.

MENTAL STATE EXAMINATION (MSE)

Appearance and Behavior:a) General appearance: Normal b) Rapport: Eye to eye contact was present and sustained

and rapport was established properly. c) Posture and movement: Normal d) Social behavior: Normal and culturally appropriate

social behavior was present. Affect: Depressed. Mood: Emotional liberality Speech:

Quantity: Normal speech Quality: Rhythm and volume is appropriate Quality: Relevant.

MENTAL STATE EXAMINATION (CONT.)

Thought: Stream:none Content: none Form: none

Perception: None Cognition:

Consciousness: intact Orientation: about time, place and person is intact. Attention: patient is attentive. Concentration: concentration is aright.

MENTAL STATE EXAMINATION (CONT.)

Memory : Immediate: Intact Recent : Intact Remote: Intact

Intelligence : Average (based on clinical observation) Abstract thinking: Intact Judgment : Intact Insight : Intact

DIAGNOSIS

Conversion/dissociative disorders

ASSESSMENTIn depth interview Objective rating: Psychological evaluation using Children’s

Apperception Test (CAT) Subjective rating:

Total wellbeing (where 0 means lowest level of the wellbeing and 100 means highest level of the wellbeing)

FORMULATION

Predisposing and precipitating factor: A gradual decline in performance was reported He

feels discriminated and victimized by his class teacher and expressed strong resentment for not getting required attention and reinforcement from his class teacher.

MANAGEMENT

Multi disciplinary Management might be required

but in this case ,very good response found after

Pschycotherapy sessions.

MANAGEMENT (CONT.) Five sessions of Pschycotherapy On the first visit the child was seen to be sitting in the chair

with his legs held parallel to the ground since he was not able to flex his knees. He was dragging his feet while walking. The child was provided reassurance regarding the management of symptoms. Possible consequences of persistence of symptoms were also discussed. He was made to do movement exercises by slightly moving his feet preceded by deep breathing. As he was moving his feet suggestions of increased flexibility were given. With continued effort of 10 – 15 minutes he could bend his knees and sit in a normal position for a brief period. His effort to move his lower limbs were encouraged and appreciated. The child was asked to continue the movement exercises at home and given a suggestion that he would flex his knees at right angles.

MANAGEMENT (CONT.) In the second session held the next day child walked less stiffly

and was able to bend his knees to right angles as suggested. His parents were educated about the psychosomatic nature of his symptoms and advised to encourage him for developing a symptom free lifestyle. They were also told not to pay attention to his complaints of physical symptoms.

By the third session held the next day, his gait was normal. He reported to have pain in his lower limbs but was able to flex his knees. He was still unable to bend his knees fully. He was reinforced for the improvement and asked to continue the movement exercises at home and resume all usual activities.

MANAGEMENT (CONT.) Addressing the school related issues he was allowed to talk

about alternatives available to deal with the current situation. His parents were advised to allow him to communicate his difficulties freely, look at issues objectively and help him develop an adaptive coping style. The child was asymptomatic and had resumed his earlier routine by the fourth session which was held the next day. He was seen once more after a period of one week during which improvement was maintained. Follow up was maintained for 2 more sessions with the parents with a week’s interval in between during which also improvement was maintained. Telephonic contact was maintained up to 3 months during which he continued to be symptom free.

MANAGEMENT (CONT.) Social Management

The purpose of social management is to readjustment the client in the family as well as in the society

To inform the family members, peer groups, school teacher about client’s situation

To counsel the family members and school teachers to be patience on client

To counsel the peer groups to behave properly with the client To help the client for readmission in SCHOOL

Social management was covered for this case.

TREATMENT TECHNIQUESI have applied the supportive treatment strategy of

Social case work for this client

Treatment Strategy PurposeReassurance Self- confidence

Providing information Based on client’s needs, such as Medication, Disease, Readmission, etc

Cognitive behavior therapy cognitive restructuring Psychodynamic therapy addressing symptom connections

to trauma and dissociationVentilation Emotional release, Identifying hidden

cause etcDirect Intervention Making favorable or controlling

discussion.Advice Social skill development

Self- awareness Understanding Himself and manage the stress

OUT COME The child was asymptomatic and had resumed his

earlier routine.

COMMENTS Conversion/dissociative disorders is often misunderstood and challenging to

diagnose.

Prompt intervention is essential to improve outcomes and avoid prolongation of

distressing symptoms.

Psychoanalysis should be undertaken after excluding neurological causes and

other medical conditions as the cause of a patient’s symptoms,

. Acute psychological stress may be found to have precipitated the conversion

symptoms, as occurred with our patient.

Once the diagnosis is made, treatment generally warrants a multidisciplinary

approach that is supportive and includes a mental health professional.