Dissociative disorders in the Sultanate ofOman

Chand SP, Al-Hussaini AA, Martin R, Mustapha S, Zaidan Z, ViernesN, Al-Adawi S. Dissociative disorders in the Sultanate of Oman.Acta Psychiatr Scand 2000: 102: 185±187. # Munksgaard 2000.

Objective: To study the clinical manifestations and psychosocial aspectsof dissociative (conversion) disorders (DD) in the Sultanate of Oman.Method: A retrospective analysis was made of data derived from caserecords of patients admitted as in-patients to the Sultan QaboosUniversity Hospital, Oman, over a period of 8 years.Results: A higher prevalence of DD was noted in Oman compared towestern countries. The female preponderance was less marked in Oman.The most common presentations were dissociative convulsions,dissociative motor and dissociative trance disorders. Interpersonaldif®culties with family and academic problems were the importantidenti®ed precipitants.Conclusion: The study highlights the characteristic clinical andpsychosocial features of the dissociative phenomena in Oman.

Suma P. Chand,Ala Aldin Al-Hussaini,Rodger Martin, Sawsan Mustapha,Ziad Zaidan, Nonna Viernes,Samir Al-Adawi

Department of Psychiatry and Behavioural Medicine,

Sultan Qaboos University Hospital, Muscat,

Sultanate of Oman

Key words: conversion; dissociative disorder

Dr Suma P. Chand M Phil, PhD, CPsychol, Senior Clinical

Psychologist, Department of Psychiatry and Behavioural

Medicine, Sultan Qaboos University Hospital, PO Box

38, PC 123, Muscat, Sultanate of Oman

Accepted for publication March 28, 2000

Introduction

Dissociative (conversion) disorders (DD) manifestas disruptions of the normal integration betweenmemories of the past, awareness of identity, andimmediate sensations and control of bodily move-ments. Physical disorders do not explain thesymptoms and evidence for psychological causationis required to make a diagnosis of DD (1).Epidemiological studies indicate that conversionand dissociative phenomena are more prevalent inthe developing countries compared to the moredeveloped western countries (2±4). There have beenfew reports regarding the clinical features andpsychosocial aspects of DD from the Arab coun-tries (5, 6). Oman has a total population of 2million. At present there are 51 hospitals, 115 healthcentres and ®ve polyclinics. The Sultan QaboosUniversity Hospital (SQUH) receives referrals fromhospitals, health centres and polyclinics from allover the country. The present paper presents an8-year retrospective analysis of patients of DDadmitted in the SQUH, Oman.

Material and methods

The patients diagnosed as DD over an 8-year periodwere referred from other health-care institutions aswell as other departments within SQUH to the

Psychiatry Department at SQUH. In the PsychiatryDepartment the referred patients were assessed anddiagnosed as DD by the psychiatry team, which isheaded by a psychiatry consultant.

The data for the present study were obtained bythe ®rst author from the case records of patientsadmitted in the hospital during the period of June1990±June 1998. Information extracted from thecase records included demographic variables, illnessvariables, and psychosocial variables. A currentdiagnostic classi®cation was made using theICD-10.

Results

During the 8-year period of June 1990±June 1998,a total of 111 adult and adolescent patients wereadmitted to the SQUH, Oman, with a diagnosisof dissociative (conversion) disorder. They formed0.3% of the total 41 465 patients admitted to thehospital and 8.6% of the 1294 patients admittedto the psychiatry ward. An analysis of the numberof admissions each year indicated a steadyincrease from one admission in 1990 to 34admissions in 1998. Sixty-six (59.5%) comprisedadult patients and 45 (40.5%) comprised adoles-cent patients. The majority of the patients, that is89 patients (80.2%), fell within the age range of

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13±30 years. Forty-four patients (39.6%) com-prised males and 67 (60.4%) comprised females.Fifty-three patients (47.7%) had manifested dis-sociative symptoms earlier in life. The mean agefor adolescents was 16.46 years and for adults itwas 28.3 years. The overall mean age was 22.4years.

The majority, that is 79 patients (71.2%) had onlya single hospitalization, 20 patients (18.0%) hadtwo hospitalizations, eight patients (7.2%) had threehospitalizations, three patients (2.7%) had four hos-pitalizations and one patient (0.9%) had sevenhospitalizations. The mean length of each hospita-lization was 10.3 days.

The distribution of the patients according tothe categories of DD is shown in Table 1. Themost common presentation was that of dissocia-tive convulsions. The patients with dissociativemotor disorder presented mainly with complete orpartial loss of movement in the limbs, abnormalshaking of limbs, aphonia and dysphonia. Patientswith dissociative trance disorder presented withaltered state of consciousness, screaming andirrelevant talk. Patients with dissociative disorderof movement and sensation presented with loss ofsensation and numbness. Of the two patients withdissociative sensory loss, one presented withcomplete loss of vision while the other presentedwith blurred vision in the left eye, anosmia of theleft nostril and left-sided ageusia of the tongue.Hallucinations, auditory and visual, were reportedin 11 patients (9.9%). Twenty-®ve patients (22.5%)also reported having headache.

Of the 111 patients, 12 patients (10.8%) had alsobeen diagnosed with depression; 12 (10.8%) had

epilepsy and one (0.9%) had been diagnosed ashaving a personality disorder.

Twenty-six patients (23.4%) came from familieswhere parental remarriages had occurred. Discord-ant intrafamilial relationships were recorded in thecase of 41 patients (36.9%). Of the total number of47 patients who had married, seven (17.1%) hadbeen divorced and 19 (40.4%) had unhappymarriages.

The quality of academic performance wasrecorded as below average in the case of 24 patients(21.6%). Twenty-one patients (18.9%) did notreceive education of any kind. Thirty-one patients(27.9%), that is 21 adolescents and 10 young adults,reported dif®culties associated with education. Thedif®culties included fear of exams, unsatisfactoryacademic performance, dif®culties coping withacademic demands and teacher-related problems.

Speci®c precipitating factors identi®ed are pre-sented in Table 2. These included dif®culties withfamily members (with parents, siblings, spouses andin-laws), academic dif®culties, interpersonal dif®-culties with non-family members, work-relateddif®culties, stressful life events (such as death/lossof a loved one and child birth), highly stressful andshameful events (such as illegitimate pregnancy andpublic humiliation) and stress in general.

Twenty-two patients (19.8%) of the patients werereported as having received traditional treatment inaddition to medical treatment.

Discussion

The results of the present study con®rm previousreports that prevalence of DD is much higher in

Table 1. Categories of dissociative disorders

Diagnostic category of DD No. of patients Percentage

Dissociative convulsions 48 43.24%

Dissociative motor disorder 23 20.72%

Dissociative trance disorder 19 17.11%

Mixed dissociative disorders 12 10.81%

Dissociative disorders of movement and sensation 9 8.10%

Dissociative sensory loss 2 1.80%

Dissociative stupor 1 0.90%

Table 2. Precipitating factors

Factors No. of patients %

Interpersonal problems with family 23 20.72%

Academic dif®culties 20 18.01%

Interpersonal problems with non-family 9 8.10%

Work-related problems 9 8.10%

Stressful life events 6 5.40%

Shameful events 2 1.80%

Stress in general 6 5.40%

Chand et al.

186

developing countries as compared to the moredeveloped western countries. DDs have beenreported to be more in women and male:femaleratios have been reported from 1:2 up to 1:5 (7). Inthe present study the overall male:female ratio of1:1.5 indicates that the male:female difference is notas great in Oman as it is in other countries.

Results indicate a steady rise in the number ofadmissions over the years. This may be a result ofthe accelerated rate of development in a countryconsisting of traditional people on whom demandshave been made to adapt to the changing psycho-social environment. The people of Oman, althoughprogressive, have strong traditional and culturalbeliefs that probably sanction the expression ofdistress in the form of dissociative symptoms.Beliefs about `Jinn' (evil spirits), of being possessed,being `cursed', being the subject of the `evil eye' iscommon in Oman. Many patients, as well as theirrelatives, tend to attribute such reasons as the causefor the DD symptoms.

The major identi®ed precipitant has been dis-cordant interpersonal relations within the family(20.7% of patients). In addition, the ®ndings ofdiscordant intrafamilial relations and parentalremarriages are all in keeping with reports thatinterpersonal issues are prominent in DDs (8, 9).

This study, although retrospective, has broughtto light characteristic features of DD phenomena in

Oman. It would, however, be useful to carry out amore detailed prospective study to obtain morede®nite and complete information.

References

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