Conversion disorders

Chapter 9
Conversion disorders


Santosh K. Chaturvedi1 and Soumya Parameshwaran2


1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India


2 Department of Psychiatry, Kasturba Medical College, Mangalore, India


Introduction


Conversion disorders have existed for many centuries, called by different names, and its nosology has changed at regular intervals. In clinical practice, these are rather common disorders in some countries and considered to be less frequent or rare in other countries. People might have conversion symptoms and when these symptoms form a predominant clinical presentation, a conversion disorder is diagnosed. Conversion symptoms may be reported in other psychiatric disorders as well. The common presentation of conversion disorders is through bodily or neurological symptoms or in loss of function of any particular system or part of body, or occurrence of sensation or pain in relation to psychological or emotional stress. The term conversion has a psychodynamic connotation, wherein the conflict or psychic anxiety was considered to be “converted” into a loss of function of a bodily part.


Historical aspects


The first description of conversion disorders is found in ancient times of Hippocrates and Galen. Greek physicians, who considered the symptoms to be specific to women, called it hysteria, which meant “a wandering uterus, hustera.” The term conversion was first used by Freud and Breuer to refer to the substitution of a somatic symptom for a repressed idea. This introduced the psychological concept of primary gain, (i.e., psychological anxiety is converted into a somatic symptom), and secondary gain of such a reaction is the subsequent benefit that a patient may derive from being in the “sick role” [1]. Conversion disorder has always remained at the interface between neurology and psychiatry since the days of Charcot, Breuer, and Freud.


Like any poorly understood phenomenon or disorder, there are many theories explaining the development of conversion disorders, namely, psychodynamic, behavioural, learning, sociocultural, philosophical, and neurobiological. Conversion disorder is conceptualised as a disorder of the brain associated with disordered emotions, in those with certain personality traits and inappropriate coping to stress, which helps the person avoid the stress rather than face it [2].


Epidemiology: Where are the conversion disorders of yesteryear?


Conversion disorders are universal in their presentation. These are one of the common presentations of common mental disorders or neurosis. In the last five or six decades, conversion disorders have been reported less commonly in the Western and developed countries. It was considered that conversion disorders are a common form of presentation of reaction to the stress in some traditional societies. One Indian epidemiological survey repeated 10 years and 15 years later in the same settings, which confirmed that the prevalence of conversion disorders or hysteria is on the wane [3]. The decline in hysteria was probably due to the improved socioeconomic status of women, because of greater economic power in the younger age group [4]. and increasing psychological sophistication of the population . The proportion of patients diagnosed as dissociative disorders during a decade in a psychiatric hospital ranged between 1.5 and 15.0 per 1000, reiterating the fact that dissociative disorders continue to exist and form a sizable proportion of mental disorders [5]. Of these, two-thirds of the cases were dissociative motor disorders and dissociative convulsions (conversion disorders) and were the most frequent [5]. The total incidence of conversion disorder has been estimated at 2.5–500 per 100,000 in the general population and at 20–120 per 100,000 among hospital inpatients [6]. In clinical practice, psychiatrists come across both conversion symptoms in depressive or anxiety disorders, as well as conversion disorders. Somatoform disorders are a common differential diagnosis for conversion, discussed later in the chapter.


In this chapter dissociative disorders would also be considered under conversion disorders.


Terminology: There’s a lot in a name!


It is not an easy task to provide suitable names for symptoms unexplained by underlying organic pathology; hence, these have to meet certain criteria and description. The preferred term should be acceptable and of use to patients and doctors in a way that facilitates appropriate treatment. Despite being in official nomenclature since 1935, “conversion” has not achieved the dominance as a term among clinicians and researchers that might have been hoped for [7]. The term should also reflect etiological neutrality about the nature of a problem that we still do not properly understand. The term conversion disorder implies a specific psychological etiology in which intrapsychic distress is “converted” into “somatic” symptoms, thereby reducing the distress. Thus, it is not etiologically neutral. While not necessarily wrong, the conversion hypothesis is as yet unproven and must compete with other plausible psychological and biopsychosocial theories [7].


In clinical practice, a wide variety of terminology is used between countries and between physicians, neurologists, psychiatrists, and other health care providers (see below).


Stone and colleagues [7] have suggested, like many others, that the name conversion disorder should be changed. According to them, conversion disorder is not a useful term for this group of symptoms. Functional neurological symptom disorder, dissociative neurological symptom disorder and psychogenic neurological symptom disorder are possible alternatives suggested by them. One could take these suggestions with a pinch of salt. The term “functional” is poorly understood: Does it mean loss of function of a body part (as in monoparesis) or defect in function of the brain in the lack of anatomical and pathological evidences for the symptom. It perhaps implies a lack of morphological or biochemical abnormality; nevertheless the functions are impaired. With the growing use of functional magnetic resonance imaging fMRI, the term functional would add to the confusion, that functional disorders need a functional MRI. The term dissociative, like conversion, has its roots in psychodynamic defense mechanism. Psychogenic would imply the role of psychological factors and confirm their role in causing the symptoms and being an etiological term.


The arguments [8, 9] for abandoning the term conversion disorder, summarised by Reynolds [10], reiterate that the concept of conversion is based on a questionable psychoanalytical concept, and it is not widely used by general physicians and neurologists, and some assume it is not liked by patients. The current conversion diagnostic criteria require a psychosocial association with onset of symptoms, which is difficult to find in a minority of patients, and when present is sometimes of questionable relevance; and the exclusion of malingering, which is difficult, if not impossible. Neurologists tend to use their own terminology and concepts, commonly “functional” but with a variety of meanings, most often “non-organic” [11]. The heterogeneity of conversion disorders does not make it any easier to select a suitable, acceptable name for such disorders.


Difficulties in diagnosing conversion disorders


Conversion, as a disorder, has been a condition difficult to understand, explain, and manage. No wonder it is difficult to diagnose confidently and reliably. As the ages have gone by, different explanations have been propounded; the most popular were psychoanalytical explanations a few decades back. However, the term hysteria went into disrepute and has been replaced by conversion and dissociation symptoms, which unfortunately are also rather inadequate. Hysteria is also considered a form of abnormal illness behavior [12], and current biological research is desperately exploring the pathophysiology underlying hysteria. The varied presentations, course, and outcome make hysteria a rather charmingly difficult condition to treat.


There are a number of difficulties in diagnosing conversion disorders, mainly due to their varied presentations, heterogeneity, fluctuating course, sudden appearance and disappearance of symptoms, and a lack of concern shown by the patient and absence of any confirmatory method of diagnosis. The common reasons for these difficulties are:


Due to the attitude of health professionals. Many professionals and physicians may not feel competent in identifying conversion disorders and symptoms and manage the distress symptomatically in a medical form. There are others who consider conversion as something produced voluntarily by the person and as a form of malingering or “just acting.” This attitude makes it difficult to confirm the diagnosis as these patients are brushed aside.


Most patients with conversion disorders are probably never referred to specialists, but are managed by the general practitioner. Many are not diagnosed or even identified. This may be because symptoms are minor, short-lived, or self-limiting or because the disorder is recognised as clearly having a psychological etiology. General practitioners are happier to work with the concept of nondiagnosis and may simply describe the symptoms, after any appropriate investigation, as “medically unexplained” or see the sociological concept of “abnormal illness behaviour” as being the most appropriate way of understanding these patients [12].


It has been reported that in clinical practice, neurologists use a wide variety of terms for diagnosing patients lacking a neurological basis for their symptoms, such as functional, psychogenic, and hysteria. However, when talking informally, the terms neurotic, “malingering, and supratentorial” become more common, whereas the terms somatoform and conversion, which are among the preferred official terms, were used by fewer than 30 percent of respondents in a survey of British neurologists [13].


Due to socio cultural factors. It is noted that in traditional societies expression of stress and emotional distress is prohibited or discouraged. Some cultures may lack adequate expressions or vocabulary for such emotions. In such societies, conversion symptoms form a method of expression of distress. Traditional societies willingly “accept” this physical and bodily presentation of stress rather than accepting emotional distress.


Case vignette


A teenaged girl was brought in with history of episodes of possession, in which she believed she was a goddess, and that the goddess was speaking through her and giving her orders to punish others. She heard the goddess’s voices (a religious experience or pseudohallucinations) only in the temple and when she prayed to the goddess’s idol. She had three such episodes, following a religious practice. She felt good about the episodes and did not want to lose these. She requested us to explain to her family that it was God’s work and not to blame her. After treatment, 1 month later she denied belief of the goddess. Psychological tests showed no psychotic features but a possibility of conversion hysteria. There were no clear-cut stressors identified on sentence completion tests. After medications were stopped, she was seen 3 months later without any symptoms. She maintained improvement without any medications, and a final diagnosis was one of dissociative possession syndrome.


Due to the nature of presentation. This is a common reason for the difficulties in diagnosing conversion disorders. Since the investigations and evaluations of the loss of bodily function turn out to be normal, these symptoms are considered “medically unexplained.” These symptoms are also considered to be “functional” as there is a loss of function without any anatomical or morphological abnormality. Due to the presence of perceived stress and a psychological precipitant, these disorders are considered to be psychogenic. These are methods of exclusion (of medical cause or identifiable abnormality), and hence, could be rather temporary situations till the medical cause is identified. This also depends on the sensitivity of the medical examination or investigations.


The current classifications do not provide a method for clinicians to express diagnostic uncertainty. There are patients in whom the clinician suspects conversion disorder but is uncertain of the diagnosis, perhaps because of a co-existing neurological or medical disorder or because they have insufficient clinical evidence [7]. Some patients have both a conversion symptom and a neurological disease (e.g., about 15 percent of patients with non-epileptic seizures [NES] also have epilepsy [14]) and some patients with cancer have been reported to have unexplained physical or bodily symptoms, unrelated to the underlying disease, but considered as somatoform symptoms or a form of abnormal illness behaviour [15].


Case vignette

May 29, 2017 | Posted by in PSYCHIATRY | Comments Off on Conversion disorders
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