Mohammed T. Abou-Saleh

582 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYbe a combination of hysterical and organic amnesia that can bedifficult to untangle. In dementia, memory loss is seen in thecontext of global cognitive impairment, which is stable over aperiod of weeks to months. The syndrome of pseudodementia alsofeatures variable memory impairment, but affective disturbance,usually severe depression, is evident 37 .DISSOCIATIVE FUGUEFugue exhibits all the features of dissociative amnesia, plus anapparently purposeful journey away from home or place of workduring which self-care is maintained. A new identity is assumedand organized travel may be undertaken to places previouslyknown and of possible emotional significance. Although there isretrograde amnesia during the fugue, behavior during fugue isnormal.A severe precipitating stress is almost universal as a precipitantof dissociative fugue. Times of marital discord, financial difficulty,major role change or personal loss may precede the fugue.Depressed mood is frequently present before fugue symptoms aredisplayed 34 .Fugue is rare in elderly people. Because its features, with theexception of travel, are identical to those of dissociative amnesia,it has been proposed that the two disorders be considered as one.The most important differential diagnosis is the group ofsomatoform disorders (although DSM-IV classifies conversiondisorder as a somatoform disorder instead of a dissociativedisorder). In the latter, the patient’s presentation centers aroundpersistent requests for medical attention and pervasive concernwith the perceived medical disorder; patients with conversiondisorder are much more likely to take their presumed illnesses instride. Conversion disorders generally begin in adolescence andyoung adulthood, and occur in single or recurrent episodes withsubstantial remission. Somatoform disorders may not increase inprevalence with increasing age, but they tend to assume thequality of a pervasive character style with little remission.Most conversion disorders remit with non-specific, supportiveinterventions. Hypnosis, anxiolytics and behavioral relaxationexercises may be helpful. Also, psychotherapy aimed at helpingthe patient recognize and cope with the psychosocial stress thatprovoked the symptom can be impressively beneficial if thepatient can be engaged in a cooperative alliance of therapeuticcuriosity.The prognosis of conversion disorder is generally good, sinceconversion symptoms are of short duration with abrupt onset andresolution. A few become chronic, and some recur, mostcommonly when the precipitating stress is chronic or recurrent,when there is other psychopathology or when there is markedsecondary gain.TreatmentTherapy for dissociative amnesia and dissociative fugue isvirtually identical. Patients usually seek treatment after theamnestic period has ended. They desire help in recoveringmemory of events during the fugue. Hypnosis and short-actingbarbiturates have been used to reconstitute repressed memories,although typically they return spontaneously. Psychodynamicpsychotherapy has been used to facilitate resolution of conflictsthat lead to fugue states. This treatment may decrease thevulnerability of the patient to dissociate in future times of stress 38 .DISSOCIATIVE DISORDERS OF MOVEMENT ANDSENSATION (CONVERSION DISORDERS)In conversion disorder, there is a loss or alteration in movementsor sensations (usually cutaneous) in a patient presenting as havinga physical disorder. No somatic condition can be found, however,that explains the symptoms. Instead, the symptoms represent thepatient’s concept of the physical disorder, which may be atvariance with physiological or anatomical principles. Here, mentalstate and social situation suggest that disability resulting from theloss of function is helping the patient to escape an unpleasantconflict, or helps the patient to express dependency or resentmentindirectly. Conflicts may be evident to others, but the patientoften denies their presence and attributes distress to the physicalsymptoms or the resulting disability.In making the diagnosis it is essential that: (a) evidence of aphysical disorder is absent; and (b) sufficient knowledge ofthe psychological and social setting and personal relationships ofthe patient allows a convincing formulation of the reasons for thedisorder.Predisposing factors to conversion disorder are premorbidabnormalities of personal relationships and personality. Also,close relatives or friends may have suffered from physical illnesswith symptoms resembling the patient’s. A few patients establish arepetitive pattern of reaction to stress by production of thesedisorders, which can continue into middle and old age 2 .NEURASTHENIA (FATIGUE SYNDROME)Historical PerspectiveGeorge Beard introduced the term ‘neurasthenia’ in 1869. Heviewed neurasthenia as a physical illness due to loss of nervestrength. Janet differentiated psychasthenia from neurasthenia.Freud similarly separated anxiety neurosis, a ‘‘psychoneurosis’’,from neurasthenia, an ‘‘actual neurosis’’ he attributed tomisdirected libidinal energy.In World War I, the syndrome was defined by the term ‘‘shellshock’’;in World War II, ‘‘operational fatigue’’. Although itremains in ICD-10, the diagnosis of neurasthenia was deletedfrom DSM-III and replaced by dysthymia. In the USA thesymptom cluster known as chronic fatigue syndrome is almostidentical to the current ICD classification of neurasthenia 39–41 .Clinical FeaturesNeurasthenia is characterized by persistent, distressing complaintsof fatigue after mental effort, or complaints of bodily weaknessand exhaustion after minimal physical effort, along with at leasttwo of the following: muscular aches and pains, dizziness, tensionheadaches, sleep disturbance, inability to relax, irritability ordyspepsia. If autonomic or depressive symptoms are present, theycannot be sufficiently persistent and severe to fulfill the criteria forany more specific disorder 2 .Differential DiagnosisDifferential diagnosis includes primarily major depression andsomatoform disorders. In the elderly it is especially important torule out depression, since somatic complaints and fatigue arecommon presentations of depressive disorders in late life. Physicalsymptoms with no demonstrable organic pathology are theessential features of somatoform disorders. However, thesecomplaints do not include the specific physical symptoms offatigue or exhaustion found in neurasthenia.