Abstract
A recent article in the Australian and New Zealand Journal of Psychiatry [1] reported on dissociative trance disorder within the context of psychosocial stressors. The findings indicated that such states may well be mediated by individual coping mechanisms. Trance states, as forms of dissociation, are not well understood [2]. We wish to report on a female adolescent who manifested with features of dissociative trance disorder (DTD) [3] as part of recovery from major depression following the death of her father.
The patient, a 17-year-old Indian, was admitted following excessive weight loss within the context of features of a major depressive episode. She had lost 11.4 kg since the death of her father, weighing 26.6 kg on admission. Her height was 1.5 m which gave her a BMI of 11. It was initially thought, by the referring doctor, that she was suffering from anorexia nervosa. This was not borne out on assessment. She presented with features primarily of a mood disorder. Antidepressant medication was initiated, paroxetine 20 mg daily. The choice of medication was influenced by comorbid features of generalized anxiety. In spite of a progressive improvement in mood symptoms she reported persistent sleep disturbances. Accordingly she was commenced on a low dose of trazadone (50 mg nightly) with good effect.
During the course of treatment she unexpectedly manifested with an altered state of consciousness associated with body movements best described as shaking. This involved her head as well as legs. At such times she would be seated on the bed, but would never fall to the ground. There was no associated incontinence or features in keeping with an ictal episode. Following such an episode, which would remit spontaneously, there was some recollection of events: specifically, her ability to feel an ‘episode’ coming on, which was usually in the form of a headache. A subsequent sleep deprived EEG was normal. Aside from seizures, the possibility of a medication-induced state was also considered. Medication was stopped. Over time it became apparent that as her mood had started to improve, issues around the death of her father were being raised. It was noted that discussion of his death or viewing of photos preceded the emergence of the states. The patient acknowledged the relationship and it was decided that intervention should be less intense concerning the loss. The episodes diminished and medication was reintroduced as before. She remains an inpatient but with ongoing progress at both a physical and emotional level.
The role of a psychosocial stressor in precipitating DTD was clearly demonstrated in this particular case. This is the first reported instance of DTD in our adolescent unit, and to our knowledge, from South Africa. It would appear not only to add to the literature on DTD but also to support the finding that establishing precipitating psychosocial stressors is a critical component of an intervention strategy [1]. Moreover, that aside from religion, culture or any of the psychosocial stressors documented in the earlier study [1], coping in the face of bereavement may be an associated precipitant stressor.