1 INTRODUCTION Dissociative disorder (conversion disorder), is symptoms and signs affecting voluntary motor or sensory function that cannot be explained by a neurological or general medical condition1.The reported prevalence in the neurology clinics of unexplained symptoms among new patients is very high (between 30 and 60%) and affects between 0.011% and 0.5% of the general population2. Previous prevalence studies found incidence rates of 22 and 11 newly diagnosed cases per 100,000 person-years, in Iceland and US respectively3(Gelder et al 2001). In Western societies the rate of Dissociative disorder (conversion disorder), is 1%to 3% in outpatient psychiatry clinics, whereas in non- Western societies it is about 10%4(Carson et al 2000). Dissociative disorder (conversion disorder), may develop at any time between early childhood and late old age, it is reported to be most common between 15 and 35 years of age. Dissociative disorder (conversion disorder), is more prevalent among females compared to males, with a ratio between 2:1 and 10:15(Nimnuan et al 2001). Dissociative disorder (conversion disorder), is also more prevalent in rural areas, in developing countries, among people of low socioeconomic classes, among undereducated people ,and among those with relatively low medical knowledge6(snijders et al 2004). In our study, we study about socio-demographic profile of the Dissociative disorder (conversion disorder) in our tertiary care centre. As far as presentation of dissociative disorders (conversion disorder) is concerned, previous studies reported that almost any physical symptom can be produced but most 2 common manifestations are those of similar to motor manifestations of neurological disease, for example: paraparesis, pseudoseizures and aphonia2. The patients with conversion disorder usually report in emergency department with multiple neurological symptoms including weakness, seizures like activity and loss of consciousness. In a hospital-based study, the commonest presenting symptom was found to be 'pseudoseizures', which presented in 45.71% female subjects as compared with 26.65% in male subjects7 (Tollison et al 2002). Another study revealed that 31.3% cases presented with unresponsiveness - a symptom which does not fit any diagnostic criteria, jerky movements, aphonia and sensory loss, and 18.1% others. Another study reported pseudoseizures, paralysis, tremors, aphonia gait disorders, mutism, blindness and anesthesia in decreasing frequency8(Shahid et al 2015). In our study we study about the types of presentation in Dissociative disorder (conversion disorder. Previous studies states that dissociative disorder (conversion disorder), have psychiatric comorbidity with the prevalence of 60-90%2.Comorbidities significantly affect the prognosis and the treatment of dissociative disorder (conversion disorder). The most common psychiatric comorbidities are mood disorders, anxiety disorders. In a study by Bowman et al (1996), depressive disorders were reported to accompany Dissociative disorder (conversion disorder), at a rate of 88%9. In another study by Kuloglu et al (2003)10, comorbidity rates for depression, anxiety disorders, and adjustment disorders with Dissociative disorder (conversion disorder), were found to be 35.3%, 34.8% and9.6%, respectively. Kaygisiz et al (1999)11 reported that 83.6% of patients with 3 Dissociative disorder (conversion disorder), had at least one psychiatric comorbidity, and rates for depressive disorders were reported to be between 34.3% and 50%. Personality disorders also accompany Dissociative disorder (conversion disorder) . In a study focusing on patients with Dissociative disorder (conversion disorder),the rates for borderline personality disorder, histrionic personality disorder, and antisocial personality disorder were 55%, 16%, and 11%, respectively (Feinstein et al, 2011)12. Thus the aim of the study was to study the types of presentation and psychiatric co- morbidities in Dissociative disorder (conversion disorder) in our tertiary care centre. The objectives of the study was to study the personality profile and stressful life events in Dissociative disorder (conversion disorder). We also correlated the socio-demographic and clinical profile with types of presentation in dissociative (conversion) disorder patients. 4 AIM & OBJECTIVES A study on types of presentation and psychiatric co-morbidity in Dissociative (conversion) disorder patients in a tertiary care centre. Aims: To study the types of presentation and psychiatric co-morbidity in dissociative (conversion) disorder patients. 5 Objectives: 1. Tostudy the socio-demographic and clinical profile of dissociative (conversion) disorder patients. 2. To study the prevalence of types of presentation in dissociative (conversion) disorder patients. 3. To study prevalence of psychiatric co-morbidity in dissociative (conversion) disorder patients. 4. To study the prevalence of personality traits in dissociative (conversion) disorder patients. 5. To study the stressful life events in dissociative (conversion) disorder patients. 6. To correlate the socio-demographic and clinical profile with types of presentation in dissociative (conversion) disorder patients. 6 REVIEW OF LITERATURE The prevalence rates of dissociative (conversion) disorder vary according to the population studied. (Feinstein et al 2011)13 have estimated that 20%–25% of patients in a general hospital have individual symptoms of conversion, and 5% of patients in this sample meet the criteria for the full syndrome. Carson et al 200314 estimated that not surprisingly, percentages increase in a neurologic setting. One in five outpatients seen in a neurology department had symptoms that cannot be explained by neurologic disease. (Sar et al 2004)15 studied 100 consecutive patients who was newly admitted to a neurology ward found that 14% had no evidence of neurologic disease. Data from psychiatric services give a different picture that the prevalence corresponds to the rate of 11–22/100 000 retrieved from a psychiatric care registry of the general population (Stone et al 2014)37. In Western societies the prevalence of dissociative (conversion disorder) is 1% to 3% in outpatient psychiatry services, whereas in non-Western population, it is about 10%16(Sar et al 2011). The dissociative (conversion) disorder may present at any age but is rare in children younger than 10 years or in the elderly. Studies suggest a peak onset in the mid- to-late 30s. The age ranged from 11 to 45 years with a mean of 23.6±8.67 years1(Tezcan et al 2003). 7 Dissociative (conversion disorder) is more prevalent among females compared to males, with a ratio between 2:1 and 10:1 and is also more prevalent in rural areas, and in developing countries, among the people of lower socioeconomic classes, among undereducated people, and among those with relatively low medical knowledge18(Uguz et al 2003). The dissociative (conversion) disorder is more common in women, with an age of onset across the lifespan. However, the observation made from century ago that the disorder was more frequent among people who lived in rural areas or who had lower levels of education or belonged to a lower socioeconomic class (Deveci et al 2003)19. (Tabasum et al 2006)20 studied 50 consecutive patients and found that past history of psychiatric illness was found in 22% and family history of psychiatric illness was present in 30% of patients. Stressors were present in 97% patients, out of whom, 64% had primary support group issue, and 20% had educational stress, social problems in 10%, 4% had employment and economic issues and 1 (2%) had physical health problem. The Life Events and Difficulties Schedule has been used to study stressful life events in conversion disorder patients, in which they experienced increased rates 90% of severe life events compared to general controls (Harris et al. 1996)21. The Life Events and Difficulties Schedule LEDS also revealed elevated rates of severe events in functional dysphonia for the month before symptom onset. Interestingly 50% of the dysphonia patients had an event regarding ‘conflict over speaking out’ providing evidence for secondary gain (House & Andrews, 1988)22 which has been replicated that 8 more than 50% had stressful life event before the symptoms(Baker et al. 2013)23. There is also evidence for elevated rates of historical stressors such as childhood abuse, particularly for sexual abuse in the convulsion variant of conversion disorder, with a meta-analysis of 16 which gave a pooled odds ratio (OR) of 2.94 [95% confidence interval (CI) 2.29– 3.77] compared to various control groups (Sharpe & Faye, 2006)24 A prospective study of 50 patients with conversion disorder, provided some preliminary evidence for the significant predictive value of both stressors prior to symptom onset and secondary gain which they defined as (Raskin et al. 1966)25 .Finally, recently evidence was found for the relevance of stressful life events in conversion disorder in a fMRI study where the neural correlates of recall of stressors of aetiological relevance, when compared to events of matched severity, revealed differential activation in areas involved in memory control and emotion with associated changes in motor areas, and thus providing a possible ‘conversion’ mechanism (Aybek et al. 2014)26. As the Personality disorders also accompany the conversion disorder (Rechlin etal 2010) study focusing on patients with conversion disorder, the rates for borderline personality disorder was 55%, histrionic personality