Case 23: Dissociative Convulsion Disorder—a Case Study

The SIS was administered to a 16-year-old girl, studying in 10th grade with complaints of fits of unconsciousness, convulsive movements, severe headache, low mood and nausea. She was diagnosed as a case of ‘dissociative convulsion disorder’ as per ICD-10. The SIS response projected her poor interpersonal relationship, pent-up aggression, physical abuse and disturbed family functioning. The SIS-II images were used as therapeutic intervention tool with positive change in her condition and the responses given by the subject are discussed in this case study. 

The patient had been a good, sincere student, praised by her teachers and always secured fourth or fifth position in her class among 40 students. All her birth and developmental milestones were normal, with no past history of any behavioural, psychological and neurological problems. However, her parents were not satisfied with her achievements and compelled her to get first position. None of the parents supported her on any issue except her younger brother, who used to solace her in times of distress. 

Her symptoms started four months back when she took admission in class 10th. As reported by her parents, she had frequent fits of unconsciousness with severe headache and restlessness. During her pre-board examination, she became very anxious, and often used to cry. She had a love relationship with a 23-year-old person who got married and left her. When she thinks about her lost love relationship, she becomes more anxious and suffers from severe headache with fits of unconsciousness. She further developed problems in her fingers and could not write the answers in the examination. 

She was referred for psychological evaluation and therapeutic intervention. On psychological assessment, it was observed that when she failed to solve a problem, she developed muscular rigidity which improved/disappeared after someone helped her in solving it. 

During therapeutic session, she expressed severe concern about the punitive reaction of her parents of not securing the first position in the class. In addition, during therapy, she also indicated the abusive relationship between the parents. She further reported that her father frequently abused her mother verbally as well as physically. He is also an alcoholic and would not pay any attention to his children. 

<Level B>Current Symptoms 

Her present symptoms at initial psychological evaluation included nervousness, shyness, severe headache, convulsive movements, clenching of teeth, low mood, etc. She had poor self-image and lack of self-confidence. She was diagnosed as a case of dissociative convulsion disorder as per ICD-10. Her attacks were pseudo seizures. On EEG and CT scan, no abnormality was found in cerebral activity. 

<Level B>SIS Responses 

<Level C>The Three Most Liked Images 

A7: ‘Structure of a girl in dancing position’ is a normal response suggesting her ego strength and positive attitude towards life. 

A14: ‘A pretty girl sitting on a lonely beach and is in a sad mood’ indicates her pensive mood and feeling of loneliness. In the detailed enquiry, her psychotherapist may ask her do you sometime feel this grief like this girl. 

B29: ‘A girl coming home from school and looking very happy’ may indicate her wishful thinking to have a happy home during childhood which she never had. This may also indicate her regression and wish to be a school-going girl to avoid problems. In the detailed enquiry, it should be suggested that if she participates in the therapy, she will become like this happy girl. 

<Level C>The Three Least Liked Images 

B31: ‘People standing close, arguing with each other, a bad practice’ brings out the imagery of ‘happy family (father, mother and two children)’ but she has avoided seeing a happy family because of the broken/disturbed family relationship. This reminds you of how you feel during an argument in your family. 

B5: ‘A girl pointing a pistol to other person’ may indicate her aggressive and hostile attitude towards her boyfriend that cheated her. Who this reminds you of in your real life? Have you ever wished to hurt or to even kill your boyfriend? When did you experience having broken and painful heart? 

A9: ‘A man and a woman in silent mood’ may indicate her depressive mood and poor interpersonal relationship either between parents or with her father. What it reminds you of in your real world? 

<Level B>Analysis of a Few Significant Responses 

A3: ‘A girl running and crying for help.’ Her inner cry that she needs help from others has come out on the surface. This may also be indicative of her wishful thinking to get support and help from her family members/therapist. Does this girl remind you of yourself and your inner cry? If you share your emotional feeling, your psychotherapist will be able to help you? 

A5: ‘A broken and painful heart’ may indicate her depressive feelings about her lost love relationship. 

A10: She viewed this image as ‘the face of a very sad woman and she is weeping marred by distressful life’. This may depict her projection towards her mother who often experienced physical assault from her husband and felt depressed. This may also bring out her sympathy towards her mother and her inability to help her. In addition, here question maybe asked whether she is able to weep or not, and she needs to be encouraged to express her grief which will reduce her pain and symptoms. 

A13: ‘Helpless hand is approaching’ may indicate her pensive feeling towards life. She also needs support and help. Here, she may be asked directly when she feels helpless of herself.  

A29: ‘Looks like an evil thing straight out of a horror film I saw earlier.’ The image in A29 is more like TAT’s blank card which works as pure projection and the imagery of ‘evil thing and horrifying thoughts’ suggest her traumatic memories. Here question may be asked directly about any post-traumatic dream which she may be experiencing. It is always important, whenever possible, to link her inkblot responses to her disturbing symbolic ‘nightmares’. 

A31: ‘A man and woman talking with each other, something serious.’ This may indicate disturbed relationship either with her boyfriend or parents. Question need to be asked in this regard what comes to her mind. 

B3: ‘Hearts once broken never heal.’ Once again, the broken heart concept has come back suggesting her pessimistic and depressive feelings of broken love relationship. Her psychotherapist needs to suggest that while she feels hopeless because of her broken heart, psychotherapy may help her. 

B4: ‘I never fulfilled my desires in this atmosphere’ may indicate her dissatisfaction, particularly in the family. 

B6: ‘A sad girl in mirror’ indicates her own sufferings and grief-ridden unconscious material. 

B15: ‘Please stop this violence for God’ suggests that she is fed up with violence in the family. Her repeated instances of being exposed to angry and violent family scenes likely played a role in her muscular skeletal symptoms. Certain vulnerable women inhibit the expression of their own inner rage by psychomotor skeletal muscle inhibition. This mechanism has been referred to as ‘character armoured’. 

B19: ‘Burning sun and broken heart, how sad, no one gives protection.’ This may suggest her broken love affair and broken home with feelings of hopelessness and helplessness. Her therapist might well question her regarding possible suicidal ideation which she has not reported given the intense feelings of hopelessness and helplessness. 

B28: ‘Woman in distressful situation’ may indicate her sympathetic feelings towards her mother as well as her own personal anguish. 

<Level B>Interpretation of SIS Responses on Readministration (after 14 Sessions of Psychotherapy)  

<Level C>Response to the Three Most Liked Images 

A7: ‘A girl in dancing position, trying to pluck an apple’ is a good response suggesting her ego strength and positive attitude towards life. The dancing position is improvement of her earlier mood prior to psychotherapy. 

B31: ‘Father, mother and two children, nice picture with whole family’ also suggests improvement and positive change after therapy. 

B29: ‘A girl wins in a race competition.’ She has moved on from an aggressive and hostile attitude to achieve success in life is a positive change. 

Following therapy, a dramatic improvement was observed in the images previously labelled as least liked, for example, see B31 and B5. 

<Level C>Analysis of Other Significant Responses 

A3: ‘A beautiful fairy with magic stick coming from sky to resolve human problems.’ This response indicates her hope and optimistic thoughts towards life. It indicates that the supportive psychotherapy has made positive change. 

A5: ‘Eagle catching a heart.’ Although she still retains some heaviness and sadness in her heart, it is being reduced is symbolized by eagle catching her heart and flying upwards out of her past pain. 

A10: ‘A girl sees her face in mirror and smiles at herself.’ This response indicates her positive ego strength and changed mood in comparison to her perception on this image at initial testing. It also indicates that the therapy has helped her to solve her problems and developed positive attitude towards life. 

A13: ‘A powerful hand capable of security’ indicates her positive strength and self-confidence. 

A29: ‘A picture of a hill station’ indicates her happy mood and feeling of enjoyment. 

A31: ‘A girl is smiling and a boy is in a sad mood’ projects her improved state of mind in smiling shape and wishful thinking to see her ex-boyfriend in agony and sad mood. 

B3: ‘A girl giving answers of some difficult questions.’ This is the direct projection of how certainly her psychotherapist’s questions have caused her to face the painful emotional issues involved in grieving the loss of her love relationship. 

B4: ‘A mother and child’ is an improved normal response in comparison to earlier projection of depressive response on this image. 

B5: ‘A boy and a girl playing with a ball’ is a good response indicating her happy mood. 

B15: ‘A picture of many grasshoppers and spade-like knives’ is again an improved response in comparison to earlier aggressive response on this image. 

B19: ‘A bug/sun’ is again a normal response though she gave depressive response on initial testing. 

B28: ‘A mother hugging the child’ indicates good interpersonal relationship particularly with the mother. 

<Level B>Treatment Plan 

The long-term treatment plan involved improving coping strategies, family intervention and supportive psychotherapy supplemented by SIS symbolism in the therapeutic process. The combination appeared to have marked therapeutic effects and the family members have also noticed considerable improvement after therapeutic intervention.