A 23-year-old female, a receptionist by occupation, presented at the emergency of our hospital with complaints of recurrent abnormal behaviour attacks for three and half years and current recurrence for last 10 days. These behaviour attacks lasted minutes to hours. During such behaviour attacks, she responded to verbal commands and manifested abnormal behaviors, such as scratching, pulling her hair, banging her head, and hitting people nearby. She talked mimickingthe voice of her deceased father and claimed to be his soul. She tightened her limbs and moved them. These behaviour attacks were also accompanied by difficulty in breathing and apprehension.
On further inquiry, it was found that she had decreased sleep, restlessness, startled response, and worry. Her father had died of a brain tumor 2 years ago. She is the second child among four siblings and was living with her mother, 2 sisters, and a brother. She did not share a good relationship with her immediate elder sister. She expressed anger outbursts towards her elder sister for being in a better position than herself in all aspects. She had an uneventful birth history but was frequently ill during her childhood, mostly with chest infections. She was diagnosed with MRKH syndrome at 13 years of age. She then learned that she has only one lung on the right side, and she did not have a uterus, nor a vagina, and, therefore, cannot bear children. Her partner ended their 5-year relationship giving MRKH syndrome as the excuse leaving her emotionally traumatized. However, there was no history suggestive of persistent low mood or any abnormal thought or perceptual disturbance. During the mental state examination, she was uncooperative and irritable. She was diagnosed with Dissociative disorder (convulsion type) with adjustment disorder with MRKH syndrome.
She was started on Escitalopram 10 mg. The psychologist explored the triggers for her negative thoughts and planned for emotional handling of issues, anger management, and family-focused intervention. Her restlessness and worries improved but the improvement did not last long. She kept visiting emergency department in every 2–3 days, each time with increasing frequency of dissociative convulsions. The patient had 8–10 episodes of dissociative convulsions in a day. After multiple visits to emergency department, she was admitted to the Psychiatry department for further management. In the ward, the patient was consulted with the gynecology team to review the diagnosis of MRKH syndrome and possible treatment options of the same. The gynaecology team confirmed her diagnosis as MRKH syndrome with history of amenorrhea and Ultrasonography findings of abdomen and pelvis and planned an intravenous urogram, which she refused along with other related interventions. She and her mother did not want to spend any more money on the investigations related to MRKH syndrome. Baseline investigations (Complete Blood Count, Renal Function Test, Urine Routine, and Microscopic Examination and Thyroid Function Test) were normal. The ultrasound scan did not show the right kidney, and her uterus was hypotrophic (of size 2.2 cm X 0.8 cm X 1 cm).Chest X-ray showed single right lung. During the hospital stay, the psychologist had multiple sessions with her. Initial sessions were focused on assessing the knowledge of the caretaker and patient regarding her illness. Different ongoing stressors were explored and psycho-education was done about the nature of illness and the possible role of the family in the management of her symptoms. Her range of coping behaviors was explored using the Brief Cope Scale which revealed low assertiveness and avoidance-focused coping. Her mother was her primary caretaker and was also involved in the session to promote supportive interactions with her when she had dissociative convulsions. She was also trained on assertive communication and anger management skills to break the vicious cycle of interpersonal relationship issues with her family members and recurrence of dissociative convulsions and anger outbursts. There were marked improvements in the frequency of dissociative convulsions and anger outbursts with multiple sessions by the psychologist and the cut down of secondary gains. The secondary gains were the love and attention from her mother which she was not given to that extent earlier. Her mother did not complain about her anger outbursts and temper tantrums after episodes of dissociative convulsion. She was also introduced to cognitive behavior therapy (CBT) and planned for further sessions. She was discharged after 1 week with Escitalopram 10 mg and Clonazepam 0.25 mg on SOS basis.
However, the patient got readmitted for the second time after 1 week of improvement. She had developed sleep disturbance and decreased appetite. She had left her job but nobody asked her to resume her job. Mental Status Examination revealed irritability, restlessness, and preoccupation with illness. The patient used to think about her congenital condition and perceived this condition as a reason for any of her activity, events, failures, inability, difference from others. This congenital condition made her feel inferior and angry. Further assertiveness skill was explored and explained by the psychologist. The frequency of dissociative convulsion decreased in frequency and duration during the hospital stay. She was discharged with Sodium Valproate 300 mg which was optimized to 500 mg and Escitalopram 10 mg after 1 week of her hospital stay.
She was doing well for 1 year when she again got admitted for the third time for 1 week for similar problems along with the attempts of self-harm (wrist cutting). The attempts of self-harm by wrist cutting were done because of restlessness and anger outbursts when things did not happen according to her. During this admission, she had developed a hearing deficit in her left ear. She had expressed that she had difficulty hearing from her left ear which was observable and evident during the interaction as one had to repeat and speak in loud volume to communicate. However, she refused the ENT consultation despite explaining the need for evaluation by an ENT specialist for the diagnosis and management. Her symptoms gradually improved but continued having recurrent episodes of dissociative convulsions in the interval of weeks to months. The psychologist continued focused sessions on distress tolerance, the Antecedents, Behavior, Consequences (ABC) Model explored and explained along with supportive psychotherapy. Despite all the efforts, regular follow-up in months, and compliance with the medications, whenever any issues occurred about her physical condition, she had episodes of dissociative convulsions.. Nevertheless, these decreased with time to minimal episodes of 1–2 in a week.