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DIGNOSTIC DILAMA OF DISSOCIATIVE

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 Senior Resident,

Dept of Psychiatry IMS BHU,Varanasi.3

 

Abstract

Background: 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.

Aim: To find out the causes of walking difficulties in desiccative child.

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

 

Introduction


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

Case History

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.

After the 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 psychiatrist.

Investigation

Medical investigation

All investigation 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.

Psychological Investigation

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.

Discussion

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 develop interest. 

 

References

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  3. Diseth, T. (2005). "Dissociation in children and adolescents as reaction to trauma - an overview of conceptual issues and neurobiological factors". Nordic Journal of Psychiatry 59: 79–91.
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  6. Butler LD, Duran RE, Jasiukaitis P, et al. Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996; 153:42–63.
  7. Dell PF. A new model of dissociative identity disorder. Psychiatr Clin North Am 2006; 29:1–26.
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  10. Stern DB (January 2012). "Witnessing across time: accessing the present from the past and the past from the present". The Psychoanalytic Quarterly 81 (1): 53–81.