DIGNOSTIC DILAMA OF DISSOCIATIVE MOTER DISORDER IN
CHILD WITH STREES: A CASE REPORT
1 Samiksha Kaur, 2
Jai Singh Yadav, Abhisek Pathak
Psychologist SRLM Hospital, Varanasi, 1 Assist Prof.Department of Psychiatry, AIIMS New Delhi2
Dept of Psychiatry
is a disruption of and/or discontinuity in the normal, subjective integration
of one or more aspects of psychological functioning, including—but not limited
to—memory, identity, consciousness, perception, and motor control. In essence,
aspects of psychobiological functioning that should be associated,
coordinated, and/or linked are
Aim: To find out the causes of walking difficulties in
Methodology: Master A 9 year old child has consulted in OPD with
problem of walking difficulties, refusal to go school, irritability, lake of
interest, behavior problem since one year. For these problems their parents
consulted many specialties. Child was taking clonazepam 5mg (1HS), 10 mg
Amitryptiline (1HS), Escitalopram 10mg and dichlofenac since one year but he
was not responding. Hematological systemic and radiographical test of spinal
and brain were normal. Then child was seen by psychologist. IQ and CAT were
done. Individual counseling, parental and school counseling and cognitive
behavior therapy were done.
Result: with efforts to treat the child with medicines the side
effect was found and child was not responded. In IQ assessment was found to be
above the average (110-120). CAT finding shows Main stresses were his tutor was
change, death of grand mother, to whom he was much close, and poor in Hindi subject.
His family was much supportive but they have less time to spend with child.
Conclusion: some type of the motor disorder manly those existed longer
duration there is diagnostic problem arises among true neurological as well as
psychological disorders. The clear history and examination helps in management
of such patient.
Key Words: Dissociative
disorders associated with traumatic childhood experience (abuse or loss),
Experiences and symptoms of dissociation can associated with posttraumatic
stress disorder (PTSD) or acute stress disorder (ASD) to dissociative
disorders.1 it is decided whether the DSM V will group
dissociative disorders with other trauma/stress disorders.2 but symptom logy
often goes unrecognized or is misdiagnosed in children and adolescents.1,3,4 it may be
difficult for children to describe their internal experiences so diagnoses is
the basis of symtomatology of problem. Parents, caregivers and other relatives
may attempt to conceal their own abusive or neglectful behaviors; 5 symptoms can be
subtle or fleeting; disturbances of memory, mood, or concentration associated
with dissociation may be misinterpreted as symptoms of other disorders.1
Nine year old male
child was studying class IV consulted for the psychiatric OPD for with
complaints of waking difficulty, abnormal movement in upper both limb,
frequently irritability and poor interest in going to school/ or refusal to go
school. Total duration of problem arise since 2 years. The initial symptoms
raised inform of abnormal movement in upper limb, difficulty in walking from
home to catching the bus, this problem basically starting the school time. He
was referred by neurologist and advised MRI head and whole spine, in the report
of MRI there was no abnormality fond, but patient was taking medicine. Doctor
advised benzodiazepine, clonazepam 5mg (1HS), 10 mg Amitryptiline (1HS) taking
1 year. After taking 2 month of the treatment there were no any type of
improvement, but therefore, the attendant of the child consulted to the private
psychiatrist who advised some medicine (Escitalopram and clonazepam) along with
counseling. During the treatment bed waithing started. The symptoms further
decreases but child refuse to go to school, he was less interested in play,
social activity and other routine activity. But his interest change he spends
too much time for kitchen to cut vegetables, cleaning, giving instruction how
to do kitchen work. He was devoted to much time for kitchen. He acting out like
grandmother who was die before some time.
When the taking
history during the counseling, it was found that he was too much attach with
his grand mother and a school tutor. Then detail evaluation done. During the
psychological evaluation it was clear that his father has no time, he was too
much busy because he was renounced surgeon of that city. He was not allowed to
go play with colony boy because their society was not good. After death of
grand mother he was feel alone, tutor change, new tutor he not like, he want to
old teacher. He was younger child of family. Grand mother was spending more
time with them she plays with them. School performance continue poor so his
father and family member was too much stress full and his symptom of twist the
body and unable to attend the school was continue it was happened only morning
time/ school time other time he was fit. During the testing he accepted his
Hindi was to week and do not want attend the class because she was class
teacher. Academic performance was poor, his few subject was week. but IQ was
excellent. Child behavior was totally change irritability was common for every
small matter His parents more particular on his child, they would not allow
going out side for play activity with other children, neither have they freed
to take the decision himself on many matter.
evaluation and consultation of parents and child it was decided that
individual, parental and school counseling was necessary along with
psychotherapy. For this plan the session of psychotherapy started and give some
suggestion, old tutor was come again he was not able to teach class sixth
standard but he was emotionally attach with him, suggestion for school teacher
given, Holidays plan and other activity engaged with father also started.
Parents were suggest they should free to take decision and motivate them and
never appose directly on his behavior. Some management programmed given for
parents who to behave child when need of reward and when need of punishment.
For this use family therapy, cognitive behavior therapy, token therapy and play
therapy and punishment and reward.
After the four to
five session found improvement but he was not ready to go to school. His
fathers know give the time for play and other activity. He arranges some out
side to tour and enjoy with local mela and festival. All symptoms well during
the session only lake of interest and abnormal body movement remain. His father
was very much happy for improvement but anxiety about school and body movement
he not tolerate. During the counseling session it was found that child was to
much attach with father he can’t live with father. It was suggested to father
it was not any type of physical problem; it was only attention seeking
behavior. Medicine was stopped during the psychotherapy suggested by
was normal TLC, DLC, ESR, Urea Cretinin, Hormonal Test, MRI, CT, were normal
range. During the investigation child had no any significant physical or
neurological problem and not any past history. Mental status examination child
was well grown. He was quit and calm, when offered the chair he was not sit.
Psychomotor activities decreased. Speech was low intensity, eye to eye contacts
not maintain. By nature he was shy. Rapport was stabilized attention was
arousal with easy consultation. Effect was lezzy, appropriate, stable. No
perceptual abnormality was detectable. Thinking fallow- decrease, from relevant
and coherent. Conflict- adjustmetment problem in school and among family
members. Memory – normal, Judgment– intellectual, Intelligence- above average,
Physical examination- normal. All investigation was normal.
His IQ tested by
Bhatia Battery Test, it was culture free performance test. On The
basis BBT his IQ
was 110-120. CAT (Children Appreciation Test) was done.
According to DSM-IV and the ICD-10 in a new
definition fo6, 7, 8, 9“Dissociation is a disruption of and/or
discontinuity in the normal, subjective integration of one or more aspects of
psychological functioning, including—but not limited to—memory, identity,
consciousness, perception, and motor control. In essence, aspects of
psychobiological functioning that should be associated, coordinated, and/or
linked are not”. In more acute pathological dissociative presentations, the
dissociation is primarily related to traumatic and/or overwhelming experiences.
In life-long dissociative presentations such as Dissociative Identity Disorder
(DID) dissociative symptoms may routinely also occur in circumstances that are
unrelated to trauma or overwhelming
circumstances. In the other field
have argued that disorganized attachment (DA) in children can help alert
clinicians to the possibility of dissociative disorders.4 Clinicians
and researchers also stress the importance of using a developmental model to
understand both symptoms and the future course of DD's.1,3 In other
words, symptoms of dissociation may be more or less susceptible to developing
dissociative symptoms at different ages.
A 2012 review
article supports the hypothesis that current or recent trauma may affect an
individual's assessment of the more distant past, changing the experience of
the past and resulting in dissociative states.10
ConclusionPatients were diagnosed dissociative motor
disorder. Psychotherapy and management plan every session weekly one our
started. Each type of psychotherapy apply 3-6 sitting child gradually started
taking interest going to school and his abnormal symptoms gradually resolve
within 6 sitting of psychotherapy. His some symptom was change after the first
counseling, after the 3rd session 80 percent mixed with other and
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(July/August 2005). "Recognizing dissociation in preschool
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- James, B.
(1992). "The dissociatively disordered child". Unpublished paper
- Butler LD,
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- Dell PF. A new
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(January 2012). "Witnessing across time: accessing the present from
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