DIAGNOSTIC STABILITY OF DISSOCIATIVE DISORDER DURING FIVE YEAR FOLLOW-UP IN TERTIARY HOSPITAL OF NEPAL

Background : The stress on unconscious mind converted to physical symptoms or the disso- ciation of stress in to physical symptoms, called dissociative (conversion) disorder. The aim of the study was to identify diagnostic stability of dissociative (conversion) disorder during five years follow-up among patients with dissociative (conversion) disorder attending psychiatry Methods: A prospective follow-up study was conducted among 253 patients with dissociative (conversion) disorder attending in the department of psychiatry of CMC-TH. Consecutive sampling technique was used to select the sample and data was collected through face to face interview method using structured interview schedule. Obtained data were analysed using ICD-10 DCR (Di agnostic Criteria Research). The cases for study were taken during one year period. The follow up were done after 1 month, 1 year, 3 year and 5 year. The ratios and proportions were used for statistical analysis. Results: After 5 years follow up, 72 patients did not come for regular follow-up visit i.e. Subject absent was 28.46%. out of 181 patients, highest percentage of patients were diagnosed as mania/ BPAD l (N-45, 24.86%) followed by depressive disorder (N-37,20.44 %), hypomania/BPAD II (N-24, 13.26%), and conversion disorder conversion disorder (N-8, 3.16%). More than one third (N´=64, 35.36%) of the patients were improved (N-64, 35.36%). Conclusions: Diagnostic stability among patients with conversion disorders is very low after 5 years of follow up. They showed other disorders like mania/BPAD1, depressive disorder, hypomania/ BPAD II etc. Hence, regular follow-up and assessment using diagnostic criteria is essential for pa tients with dissociative (conversion) disorder for their proper treatment.


INTRODUCTION
The dissociative and conversion disorders comprise what used to be called "hysteria". Conversion disorder begins with some stressor, trauma, or psychological distress. Usually the physical symptoms of the syndrome affect the senses or movement. Common symptoms include blindness, partial or total paralysis, inability to speak, deafness, numbness, difficulty swallowing, incontinence, balance problems, seizures, tremors, and difficulty walking. These symptoms are attributed to conversion disorder when a medical explanation for the afflictions cannot be found .1 Symptoms of conversion disorder usually occur suddenly. Conversion disorder is typically seen in individuals aged 10 to 35 2 and affects between 0.011% and 0.5% of the general population 3 Dissociative disorders are conditions that involve disruptions or breakdowns of memory, awareness, identity, or perception. People with dissociative disorders use dissociation as a defence mechanism, pathologically and involuntarily. 4 Conversion disorder is defined as an illness associated with either deficits in motor or sensory function as a result of internal psychiatric conflict or secondary gain. It is thought that these symptoms arise in response to stressful situations affecting a patient's mental health or an ongoing mental health condition such as depression.ICD-10 classifies conversion disorder as motor type of a dissociative disorder. However, DSM-5 categorized it under somatoform disorder. DSM-5 also given conversion disorder as the name of subtitle functional neurological symptom disorder 5 .The concept of conversion disorder came to prominence at the end of the 19th century, when the neurologists Jean-Martin Charcot and Sigmund Freud and psychologist Pierre Janet focused their studies on the subject. Before their studies, people with hysteria were often believed to be malingering. 6 The term "conversion" has its origins in Freud's doctrine that anxiety is "converted" into physical symptoms. Hippocrates argued that a lack of regular sexual intercourse led to the uterus producing toxic fumes and caused it to move in the body, and that this meant all women should be married and enjoy a satisfactory sexual life. 7 The dissociative disorders listed in the American Psychiatric Association's DSM-5 are as follows: Dissociative identity disorder (multiple personality disorder), 8 Dissociative amnesia (psychogenic amnesia), 9 Dissociative fugue (psychogenic fugue), 10 Depersonalization disorder, Dissociative seizures. 11 There is poor diagnostic stability of conversion dissociative disorder, Patients come to emergency or OPD as diagnosed as dissociative disorder or conversion disorder however the follow up study shows other disorder like depressive disorder, mania, hypomania and bipolar disorder etc. The aim of the study was to identify diagnostic stability of dissociative (conversion) disorder during five years follow-up at Chitwan Medical College.

METHODS
A follow-up study was carried out in psychiatry department (OPD and emergency) of Chitwan Medical College Teaching Hospital (CMC-TH), Bharatpur, Nepal. Population of the study comprised of all patients with dissociative (conversion) disorder attending psychiatry OPD and emergency) department of CMC-TH. The cases were followed up total of five-year period (1 st January 2015 to 30 th December 2019). A brief explanation about the nature of the study and purposes were explained to the patients and written consent was obtained either from them or their guardians. Those patients were excluded, if there was comorbidity of psychoactive substance or those who did not gave consent.
All patients who met the study criteria and attended in the hospital during data collection period were included in the study. data was collected through face-to face interview method using structured interview schedule containing socio demographic profile (age, sex, caste, , marital status, occupation,) and disease related information. Patients diagnosis was made on the basis of ICD-10 DCR. patients were followed up after 1 month, 1 year, 3 year and 5 year and the diagnosis was revised. Those patients were excluded, if there was comorbidity of psychoactive substance or those who did not gave consent.
A continuous sequential number was given to each subject and available necessary information was kept confidential in a separate file. obtained data were analysed using descriptive statistics such as frequency, percentage mean standard deviation etc.

RESULTS
Among 253 cases, most of the cases were female (N-230, 90.90%), highest percentage of cases 49.71% were between the age group of 21-40 years 67.19% were married, 43.08% completed up to secondary level of education and more than half (52.57%) were farmers (Table 1).

DISCUSSION
The categories of "dissociative disorder" and "conversion disorder" are unique in the psychiatric nosology, because they are the only syndromes whose label carries etiological significance. On the other hand, the dissociative disorders are caused by dissociation, ostensibly, and the conversion disorders by conversion. In this way, both sets of syndromes continue the line established by the ancient diagnosis of hysteria, which name derives from the attribution of symptoms to a wandering uterus. In this study occurrence of conversion disorders was found to be higher in females (N-230, 90.90% ) than in males (N-23 ,9.09%), and a highest number of cases were age group 21-40 (N-126, 49.71%) followed by age below 20( N-103, 40.71%). This corresponds with the findings by Vyas et al, 12

CONCLUSION
Diagnostic stability of dissociative (conversion) disorder is poor. The Patients come to emergency or OPD as diagnosed as dissociative disorder or conversion disorder however the follow up after few months or few years found that the criteria fits to the another psychiatric disorder.