Psychological management of dissociative disorder

Sir, Dissociative disorders often arise as a coping mechanism in response to severe trauma, such as abuse or exposure to highly distressing events. The manifestations can range from mild to severe and may include symptoms like amnesia, identity confusion, depersonalization, and derealization. Understanding and diagnosing dissociative disorders require careful examination of the individual’s personal history, experiences, and symptoms, with treatment often involving psychotherapy to address underlying trauma and promote integration of fragmented aspects of the self.[1,2] A 21-year-old unmarried Hindu girl presented with complaints of sleep disturbances, fearfulness, episodes of unresponsiveness, and anxiety, with a duration of illness spanning 3 years. Along with her psychiatric treatment, she was referred for psychotherapy. Upon exploring her history, it was revealed that she had experienced childhood abuse trauma, including a neighbor’s attempted sexual molestation. In addition, her father was described as dominating and unwilling to listen to anyone in the family, and the patient harbored a deep fear of him. Despite her apprehension, she initially refrained from disclosing these experiences to her parents. However, as her situation worsened, she began to have nightmares, became increasingly fearful, started avoiding family functions, and struggled with excessive sweating during public interactions. Her self-esteem gradually declined, leading to an inability to take initiative in any activities, ultimately resulting in her dropping out of her studies. Negative thoughts began to pervade her mind, and she experienced frequent episodes of unresponsiveness. Assessment of the problem through behavior analysis, family interaction system, and support system was done systematically. She had a mild level of depression on the Beck Depression Inventory and a moderate level of anxiety on the Hamilton Anxiety Scale. The goal of the intervention package was to encourage and prepare her to confront challenging situations, by addressing her avoidance behaviors and anxiety by altering negative thought patterns, thereby diminishing feelings of inferiority and fostering an increase in self-esteem. This was achieved through a series of 13 sessions conducted over 10 weeks, accompanied by regular follow-ups spanning 3 months. Each session, lasting 1 h, commenced with an explanation and reassurance to the patient regarding the necessity of therapeutic intervention, followed by a collaborative discussion of the approach. The patient’s family members were provided with psycho-education about the patient’s current situation, including causative factors and prognosis. To alleviate the patient’s anxiety, deep breathing exercises were taught and training was consistently provided in each session, with the patient instructed to practice at home. The patient’s interest area was identified through externalization, and she was encouraged to engage in activities to enhance her self-esteem. Subsequent sessions focused on cognitive restructuring to address negative thoughts and faulty cognitions. The patient was guided to challenge these negative thoughts in a rational and objective manner on her own. In the final phase, family counseling was conducted, involving the patient’s father and mother. They were urged to provide support and assistance in helping the patient overcome feelings of guilt and self-blame. A marked improvement was seen in the patient after 13 sessions. Dissociative (conversion) disorders typically exhibit no discernible physical or neurological issues and share common characteristics involving either partial or complete disruptions in memory, identity awareness, sensory experiences, or control over body movements. These episodes frequently coincide with traumatic life events or heightened psychological stress. Psycho-education proved to be very useful in understanding the dynamics of the patient’s problems, as well as enabling the patient to proceed in a positive direction with the help of emotional support.[3] There was a decrease in anxiety and distress with the focus on deep breathing exercises.[4] Through family counseling, the role and importance of family support system were also explained. Reassurance and externalization of interest help her improve self-esteem.[5] Lastly, her irrational beliefs and fear were restructured with the cognitive restructuring method.[6] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author’s contribution Concept, design, definition of intellectual content, literature search, data acquisition: RR, RP, SC,DK Manuscript preparation: RR, RP Manuscript editing and manuscript review. SC, DK, Guarantor: RR. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.