Conversion Disorder

arc-de-cercle by Mari Kretz

Conversion disorder is where patients suffer apparently neurological symptoms, such as numbness, blindness, paralysis, or fits, but without a neurological cause. It is thought that these problems arise in response to difficulties in the patient’s life, and conversion is considered a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV).

Formerly known as ‘hysteria’ (unmanageable emotional excesses), the disorder has arguably been known for millennia, though it came to greatest prominence at the end of the 19th century, when the neurologists Jean-Martin Charcot and Sigmund Freud and psychiatrist Pierre Janet focused their studies on the subject. Before Freud’s studies on hysteria, people who suffered from physical disabilities that were not caused by any physical impairments, known as hysterical patients, were believed to be malingering (faking illness), suffering from weak nerves, or just suffering from meaningless disturbances. The term ‘conversion’ has its origins in Freud’s doctrine that anxiety is ‘converted’ into physical symptoms.

Though previously thought to have vanished from the west in the 20th century, some research has suggested it is as common as ever. The DSM-IV classifies conversion disorder as a somatoform disorder (characterized by symptoms suggesting a physical disorder but for which there are no demonstrable organic findings or known physiological mechanisms); while the the tenth revision of the World Health Organization’s International Classification of Diseases (ICD-10) classifies it as a dissociative disorder (disruptions or breakdowns of memory, awareness, identity and/or perception). A 2007 review stated that conversion disorder and dissociative disorders are statistically associated, share features such as a history of abuse and high suggestibility, and likely have common underlying causes. It recommended that DSM should follow ICD-10 and reclassify conversion disorder from a somatoform disorder to a dissociative disorder.

DSM-IV defines conversion disorder as follows: One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition. Psychological factors are judged, in the clinician’s belief, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. The nature of the association between the psychological factors and the neurological symptoms remains unclear. Earlier versions of the DSM-IV employed psychodynamic concepts (the primary focus of which is to reveal the unconscious content of a client’s psyche), but these have been incrementally removed from successive versions.

In the 19th century, physicians such as Silas Weir Mitchell in the US and Paul Briquet and Jean-Martin Charcot in France developed ideas about patients sharing unexplained neurological symptoms. Charcot specialized in treating patients who were suffering from a variety of unexplained physical symptoms including paralysis, contractures (muscles which contract and cannot be relaxed), and seizures. Some of these patients sporadically and compulsively adopted a bizarre posture (christened arc-de-cercle) in which they arched their body backwards until they were supported only by their head and their heels.

The term ‘Conversion disorder’ originated with Freud. He viewed these apparently neurological symptoms as a result of the conversion of intrapsychic distress into physical symptoms. This distress was thought to cause the brain to unconsciously disable or impair a bodily function as a side effect of the original repression, which served to relieve the patient’s anxiety. However, some have claimed that patients do remain distressed by their symptoms in the long term. It has also been suggested that at least some of the classic psychoanalytic cases of hysteria (such as ‘Anna O.’) may actually have suffered from organic illness. In fact, in ‘Studies On Hysteria’ in which Breuer’s Anna O. case was first presented, Freud wrote this: ‘Others of the patient’s symptoms were not of a hysterical nature at all. This is true, for example, of the neck cramps, which I consider a modified version of migraine and which as such are not to be classified as a neurosis but as an organic disorder. Hysterical symptoms, however, regularly become attached to these.’ Freud believed that all hysterical symptoms ultimately have some organic components.

Conversion disorder can present with motor or sensory symptoms including any of the following: Impaired coordination or balance; Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor conversion disorders); Impairment or loss of speech (hysterical aphonia); Difficulty swallowing or a sensation of a lump in the throat; Urinary retention; Psychogenic non-epileptic seizures or convulsions; Fixed dystonia unlike normal dystonia; Tremor, myoclonus or other movement disorders; Gait problems (Astasia-abasia); Syncope (fainting); Impaired vision (hysterical blindness), double vision; Impaired hearing (deafness); Loss or disturbance of touch or pain sensation. Conversion symptoms typically do not conform to known anatomical pathways and physiological mechanisms, but instead follow the individual’s conceptualization of a condition. Typically, the less medical knowledge a person has, the more implausible are the presenting symptoms. Persons with more sophisticated medical knowledge tend to have more subtle symptoms and deficits that may closely simulate neurological or other general medical conditions.

The DSM-IV-TR does not have specific diagnosis for mass psychogenic illness but the text describing conversion disorder states that, ‘In ‘epidemic hysteria,’ shared symptoms develop in a circumscribed group of people following ‘exposure’ to a common precipitant.,

In excluding neurological disease, the neurologist has traditionally relied partly on the presence of positive signs of conversion disorder — certain aspects of the presentation that were thought to be rare in neurological disease, but common in conversion. The validity of many of these signs has been questioned, however, by a study showing that they also occurred in neurological disease. One such symptom, for example, is La belle indifférence, described in DSM-IV as ‘a relative lack of concern about the nature or implications of the symptoms.’ In a later study no evidence was found that patients with ‘functional’ symptoms are any more likely to exhibit this than patients with a confirmed organic disease. Another feature thought to be important was that symptoms would tend to be more severe on the non-dominant (usually left) side; there were a variety of theories such as the relative involvement of cerebral hemispheres in emotional processing, or more simply just that it was ‘easier’ to live with a functional deficit on the non-dominant side. However, a literature review of 121 studies established that this was not true, with publication bias the most likely explanation for this commonly held view. Although agitation is often assumed to be a positive sign of conversion disorder, release of epinephrine is a well-demonstrated cause of paralysis from hypokalemic periodic paralysis.

The original Freudian model suggested that the emotional charge of painful experiences would be consciously repressed as a way of managing the pain, but this emotional charge would be somehow ‘converted’ into the neurological symptoms. Freud later argued that the repressed experiences were of a sexual nature. As Peter Halligan comments, conversion has ‘the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms.’ Janet, the other great theoretician of hysteria, argued that symptoms arose through the power of suggestion, acting on a personality vulnerable to dissociation. In this hypothetical process, the subject’s experience of their leg, for example, is split-off from the rest of their consciousness, resulting in paralysis or numbness in that leg. Later authors have attempted to combine elements of these models, but none of them has a firm empirical basis.

Some support for the Freudian model comes from findings of high rates of childhood sexual abuse in conversion patients and from a recent neuroimaging study showing abnormal emotion processing of a traumatic event linked to motor processing of the affected limb, in a patient with conversion. Support for the dissociation model comes from studies showing heightened suggestibility in conversion patients, and in abnormalities in motor imagery. There has been much recent interest in functional neuroimaging in conversion. As researchers identify the mechanisms which underlie conversion symptoms it is hoped these will allow the development of a neuropsychological model. A number of such studies have been performed, including some which suggest that blood flow in patients brains may be abnormal while they are unwell. These have all been too small to be confident of the generalisability of their findings, however, so no neuropsychological model has been clearly established.

An evolutionary psychology explanation for conversion disorder is that the symptom may have been evolutionarily advantageous during warfare. A non-combatant with these symptoms signals non-verbally, possibly to someone speaking a different language, that she or he is not dangerous as a combatant and also may be carrying some form of dangerous infectious disease. This can explain that conversion disorder may develop following a threatening situation, that there may be a group effect with many people simultaneously developing similar symptoms (as in mass psychogenic illness), and the gender difference in prevalence.

Although it is often thought that the frequency of conversion may be higher outside of the West, perhaps in relation to cultural and medical attitudes, evidence of this is limited. A community survey of urban Turkey found a prevalence of 5.6%. Many authors have found occurrence of conversion to be more frequent in rural, lower socio-economic groups, where technological investigation of patients is limited and individuals may be less knowledgeable about medical and psychological concepts. Historically, the concept of ‘hysteria’ was originally understood to be a condition exclusively affecting women, though the concept was eventually extended to men. 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.

Treatment may include the following: Explanation; this must be clear and coherent as attributing physical symptoms to a psychological cause is not accepted by many educated people in western cultures. It must emphasise the genuineness of the condition, that it is common, potentially reversible and does not mean that the sufferer is a ‘psycho.’ Taking an etiologically neutral stance by describing the symptoms as functional may be helpful but further studies are required. Ideally, the patient should be followed up neurologically for a while to ensure that the diagnosis has been understood. There is little evidence-based treatment of conversion disorder. Other treatments such as cognitive behavioral therapy, hypnosis, EMDR (Eye movement desensitization and reprocessing), and psychodynamic psychotherapy eeg brain biofeedback need further trials.

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