PSYCHOLOGY IN ACTION Chapter 11: Diagnosis and treatment of mental disorders THE CASE OF DIZZINESS: A 46-year-old housewife was

referred by her husbands psychiatrist to a clinical psychologist for assessment. In the course of discussing certain marital conflicts that he was having with his wife, the husband had described attacks of dizziness that his wife experienced that left her quite incapacitated. During the assessment, the wife described being overcome with feelings of extreme dizziness, accompanied by slight nausea, four or five nights per week. During these attacks, the room around her would take on a shimmering appearance, and she would have the feeling that she was floating and unable to keep her balance. Inexplicably, the attacks almost always occurred at about 4pm. She usually has to lie down on a couch and often did not feel better until 7-8pm. After recovering, she generally spent the rest of the evening watching television; more often that not she would fall asleep in the lounge room, not going to bed until 2-3am. The client had been pronounced physically fit by her general practitioner, a neurologist and an ear-nose-throat specialist on more than one occasion. Hypoglycemia had been ruled out by glucose intolerance testing. When asked about her marriage, the client described her husband as a tyrant, frequently demanding and verbally abusive of her and their four children. She admitted that she dreaded his arrival home from work each day, knowing that he would comment that the house was a mess and the dinner, if prepared, not to his liking. Recently, sine the onset of her attacks, when she was unable to make dinner, he and the four kids would go to McDonalds or the local pizza parlour. After that, he would settle in to watch TV in the bedroom, and their conversation was minimal. In spite of their troubles, the client claimed that she loved and needed her husband very much. Discussion of Dizziness The woman complains of a variety of symptoms (dizziness, nausea, visual disturbance, l ss of balance) that all suggest a physical disorder; but examinations o by a number of medical specialists have failed to detect a general medical condition that could account for the symptoms. The two possible diagnoses are 1) an undiagnosed physical condition or 2) a mental disorder. The context in which these symptoms occur suggests the role of psychological factors in their development; the recur at virtually the same time each day, closely associated with her husbands arrival home from work; the husbands angry tirades and verbal abuse are undoubtedly stressful. Although the symptoms resemble those of a panic attack, there is no evidence that they occur unexpectedly, thus ruling out Panic Disorder. The disorder, therefore, is a Somatoform Disorder a mental disorder with symptoms that suggest a neurological or general medical disorder. The symptoms are linked to an alteration in sensory functioning, the diagnosis is Conversion Disorder.
Adapted from Spitzer, Gibbon, Skodol, Williams & First (1994)

PSYCHOLOGY IN ACTION Chapter 11: Diagnosis and treatment of mental disorders THE CASE OF THE WOMAN WITH FITS Mrs Chatterjee, a 26-year-old woman, attends a clinic in Melbourne with complaints of fits for the last 4 years. The fits are always sudden in onset, and usually last 30-60 minutes. A few minutes before a fit begins, she knows that it is imminent and she usually goes to bed. During the fit she becomes unresponsive and rigid throughout her body, with bizarre and thrashing movements of the extremities. Her eyes close and her jaw is clenched, and she froths at the mouth. She frequently cries, and sometimes shouts abuses. She is never incontinent or urine or faeces, nor does she bite her tongue. After a fit she claims to have no memory of it. These episodes recur about once or twice a month. She functions well in between the episodes and reports no prominent depressive or anxiety symptoms. Both the client and her family believe that her fits are evidence of a physical illness and are not under her control. However, they recognise that the fits often occur after some stressor, such as arguments with family members or friends. Mrs Chaterjee comes from a middle-class Indian family. She has been married for 5 years to a clerk in a government office. They have 2 children. Her mother-inlaw and father-in-law live with the family, and this has sometimes led to conflicts. She is described by her family as being somewhat immature, but quite social and good company. She is self-centred. She craves attention from others, and she often reacts with irritability and anger if her wishes are not immediately fulfilled. She handles routine household tasks well. On physical examination, Mrs Chaterjee was found to have mild anaemia but was otherwise healthy. She did not display any mood change and her memory was normal. An electroencephalogram (a graphical record of electrical activity of the brain; produced by an electroencephalograph) showed no seizure activity. A skull Xray was normal. Discussion of the woman with fits: The predominant symptoms of this case resembles an epileptic seizure; however, the absence of such typical features of neurologic seizures as incontinence and biting of the tongue strongly suggests that a neurological condition or general medical condition cannot explain the seizures. This is further supported by the normal results on the electroencephalogram (which is able to detect any seizure activity in the brain). The symptoms occur in response to stressful situation, so the diagnosis is
Conversion Disorder.

Follow-up - The client was treated by a clinical psychologist together with her husband. The couple was taught that the clients fits were no evidence of a serious physical illness. In addition, the husband was urged to take a more active role in handling problems that arose between the client and her in- laws and to pay more attention to the client in general but not during her fits. The couple stopped therapy after 2 moths, during which time she had no more fits.
Adapted from Spitzer, Gibbon, Skodol, Williams & First (1994)