CONVERSION

DISORDER

PRESENTED BY-

Mrs. Shalini Chhabra Sr. Lecturer

Department of Psychology

D.A.V. College for Girls

Yamuna Nagar

Meaning and Definition of Conversion Disorder:

A conversion reaction is a process whereby an unconscious conflict is transformed into a body symptom which reduces tension and anxiety by expressing conflict symbolically.

According to DSM IV (1994):“Conversion disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptoms or deficits.”

Conversion Disorder is:1.Considered to be the most complex

and difficult to understand mental disorder.

2.Important type of somatoform disorder.

3.‘Soma’ means ‘Body’. Individuals suffering from the disorders are continuously preoccupied with their state of health, with presumed

disorder or diseases of bodily organs.

4.The most common feature of all Somatoform disorders is the presence of physical symptoms that suggest a general medical condition but for which no organic basis can be found that satisfactorily explains the symptoms.

5. Somatoform disorders are:

AXIS-I clinical disorders- according to DSM IV.

6.In conversion disorder, symptoms of some physical malfunction or loss of control appear without any underlying organic pathology.

7.These symptoms resemble neurological disorders of one kind or another and are thus described as “Pseudo neurological” in nature.

Earlier View: Conversion is originally known as “ HYSTERIA.” The term ‘hysteria’ was derived from the Greek word meaning ‘Uterus.’ Hippo crates and many other ancient Greeks were of the view that ‘Hysteria’ is restricted to women.

According to them, the main cause was the sexual difficulties, particularly the wandering of a frustrated womb to

various parts of the body because of sexual desires and a yearning for children. Thus the uterus might lodge in the throat and cause chocking sensations, or in the spleen, causing Temper Tantrums.

Hippocrates considered marriage the best remedy for Hysteria.

Later on, Freud used the term “Conversion Hysteria” for these disorders.

Freud believed that the bodily symptoms were an expression of repressed sexual energy-i.e., the unconscious conflict a person felt about his or her sexual desires that was converted into a bodily disturbance.

As this was not done consciously, the person was not aware of the origin or meaning of the physical symptoms.

Contemporary View: Though still called a ‘Conversion Disorder’, in contemporary Psychopathology, the physical symptoms are now usually seen as serving the obvious function of providing a reasonable excuse, enabling an individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so.

The term ‘Secondary Gain’ which originally referred to advantages of the symptoms beyond the ‘Primary Gain’ of neutralizing intrapsychic conflict, has also been retained.

Generally, it is used to refer to any circumstance, such as attention from the loved ones or financial compensation, that would tend to reinforce the maintenance of disability.

Decreasing Incidence:Conversion Disorder was once common in civilian and especially in military life.

This disorder was the most frequently diagnosed psychiatric syndrome among soldiers in World War I and II.

(Conversion symptoms- such as paralysis of the legs- enabled a soldier to avoid an anxiety arousing combat situation without being labeled as coward or being

subjected to court martial).

Today Conversion Disorder constitutes only 1 to 3 percent of all disorders referred for mental health treatment.

The decreasing incidence of this disorder seems to be closely related to our growing understanding about medical and psychological disorders.

Conversion Disorder apparently loses its defensive function if it can be readily

shown to lack an organic basis.

As a result, present cases of Conversion Disorder show symptoms of strange diseases that are harder to diagnose, such as convulsive seizures or some malfunction of internal organs.

Moreover, these symptoms are not so obviously and directly related to the nature of the problem with which the person is attempting to cope.

Specific culture, age and gender features:Conversion Disorder has been reported to be more common in-rural populations, individuals of lower socio-economic status, and in individuals who are less knowledgeable about medical and psychological concepts.

Higher rates are reported in developing nations and regions, with the incidence

generally declining with increasing development.

In children under 10 years, symptoms are usually limited to gait problems or seizures.

More common in women than in men, ratio varying from 2:1 to 10:1.

In women, symptoms are much more common on left than on the right side of the body.

In men, an association with Antisocial Personality Disorder is evident.

Familial Patterns:Conversion Symptoms are frequent in relatives of individuals with Conversion Disorder.

More common in Monozygotic rather than Dizygotic twin pairs.

Course:The onset of Conversion disorder is generally from late childhood to early adulthood, rarely before age 10 years or after age 35 years.

The onset of Conversion Disorder is generally acute, but gradually increasing symptomatology may also occur.

Typically, individual conversion symptoms are of short duration. Symptoms will

remit within 2 weeks in most cases.

Recurrence within 1 year in most cases is common.

Factors that are associated with good prognosis include acute onset, presence of clearly identifiable stress at the time of onset, a short interval between onset and the institution of treatment, and above average intelligence.

S E N S O R Y S Y M P T O M S M O T O R S Y M P T O M S V IS C E R A L S Y M P T O M S

S Y M P T O M S

TYPES OF SENSORY SYMPTOMS

ANESTHESIA-Loss of sensitivity

HYPESTHESIA-Partial loss of sensitivity

HYPERESTHESIA-Excessive sensitivity

ANALGESIA-Loss of sensitivity to pain

PARESTHESIA-Exceptional sensations e.g., heat

Some examples of sensory symptoms:

Visual Symptoms as reported by Ironside et al., (1945) in their classic study on airmen in World War II.

1.Blurred vision

2.Night blindness

3.Double vision

4.Photophobia-extreme sensitivity to light

5.A combination of intermittent visual failure and amnesia.

6.Deficient stereopsis- the tendency to look past an object during attempts to focus on it.

7.Restriction in the visual field.

8.Intermittent loss in vision in one eye

9.Colour blindness

10.Jumping of print during attempts to read.

11.Failing day vision.

Important Observation in the Study:Symptoms of each airman were closely related to his performance duties. E.g., night fliers mostly showed night blindness and day fliers mostly showed failing day vision.

MOTOR SYMPTOMS

PARALYSIS CONVERSION REACTION

TREMORS

TICS

ASTASIA- ABASIA

APHONIA

MUTISM

Examples of motor symptoms:

1.Paralysis Conversion Reactions:

These reactions are usually confirmed to a single limb such as an arm or a leg, and the loss of function is usually selective e.g., as in ‘Writer’s Cramp’.

2.Tremors(muscular shaking) and Tics(localized muscular twitches):

Symptoms include contractures, which

usually involve flexing of the fingers and toes, or rigidity of the larger joints, such as the elbows and knees.

3.Astasia-Abasia:

This is a type of walking disturbance in which an individual can usually control leg movements when sitting or lying down, but can hardly stand and has disorganized walk, with both legs wobbling about in every direction.

4.Aphonia:

This is a very common speech related conversion disturbance, in which an individual can talk only in whisper, but can usually cough in a normal manner. This usually occurs after some emotional shock.

5.Mutism:

In mutism an individual is unable to speak. These types of conversion reactions are

relatively rare. Occasionally, symptoms may involve convulsions, similar to those in epilepsy. People with such symptoms, however, show few of the usual characteristics of true epilepsy. They rarely,if ever, injures themselves in falls, their pupillary reflex to light remains unaffected; they are able to control excretory functions; and they rarely have attacks when others are not present.

VISCERAL SYMPTOMS

LUMP IN THE THROAT AND CHOKING SENSATION

NAUSEA AND VOMITING

DIFFICULTY IN BREATHING

HICCOUGHING AND SNEEZING

COUGHING SPELLS

COLD AND CLAMMY EXTREMITIES

BELCHING

GREAT DEGREE OF SIMULATION OF ACUTE SYMPTOMS

P seu d o a tta ck o fA cu te A pp e n d ic it is

C o n ve rs ion R ea c tion s o fM a la ria a n d T u b e rcu lo s is

P seu doP re g na n cy

E xa m p le s o f o rga n ic sym pto m s

Diagnosis in Conversion Disorder:Several criteria are commonly used for distinguishing between conversion disorders and true organic disturbances:A certain unconcern(“la belle indifference”), in which the patient

describes what is wrong in a rather matter-of-fact way, with little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight.

The frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated.

The selective nature of the dysfunction.

Under hypnosis or narcosis( a sleep like state induced by drugs) the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist.

Distinguishing Conversion from Malingering/ Factitious Disorder:Sometimes, of course, persons do

deliberately and consciously feign disability or illness. For these instances, the DSM distinguishes between malingering and factitious disorder on the basis of the feigning person’s apparent goals such as an award of money or avoidance of an unwanted duty or obligation, in factitious disorder, the person’s goal is the more general one of maintaining such personal benefits as the “sick role” may provide, including the attention & concern of medical personnel.

Diagnostic Criteria for Conversion Disorder (DSM IV):One or more symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition.

Psychological factors are judged to be associated with the symptom or deficit because the initiation of the symptom or deficit is preceded by conflicts or other

stressors.

The symptom or deficit is not intentionally produced.

The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of the substance, or as a culturally sanctioned behaviour 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, and is not better accounted for by another mental disorder.

Precipitating Circumstances:1.The individual experiences a desire to

escape from some unpleasant situation.

2.He may be having a wish to be sick in order to avoid the situation.

3.Finally under additional and continued stress; begins to show appearance of symptoms of some physical ailment.

4.The individual typically sees no relations between the symptoms and the stress situation.

5.Particular symptoms are usually of a

previous illness, or are copied from other sources, such as, symptoms observed in relatives, or seen on television, or read about in magazines.

6.Sometimes, Conversion Disorders seem to stem from feeling of guilt and the necessity for self punishment.

7.Once the response is learned, it is maintained because it is repeatedly reinforced- both by anxiety reduction or by whatever gained in terms of sympathy

and support that result from being disabled.

Etiology:

Psychoanalytic Theory:Breuer and Freud(1895) proposed that a Conversion Disorder is caused by an experience that has created great emotional arousal.The affect, however, is not expressed, and the memory of the event is cut off from the conscious

experience.

They proposed two explanations why the affect is not expressed:

1.The experience may have been so distressing that the person could not allow it to enter consciousness and is, therefore, repressed it. OR

2.The experience may have occurred while the person was in an abnormal psychological state such as semi-hypnosis.

In both situations, the specific Conversion Symptoms are casually related to the traumatic event that preceded them.

Later, he hypothesized that conversion disorders are rooted in an early, unresolved “Electra Complex.”

Thus the primary gain from the Conversion Disorder is the avoidance of previously repressed “Id” impulses.

Behavioural theory:Behavioural account of the development of Conversion Disorders was proposed by Ullmann & Krasner(1975).

According to them a person deliberately adopts conversion symptoms to gain some end.

The person attempts to behave according to his or her own conception of how a person with a disease affecting the

motor or sensory abilities would act.

This theory specify two conditions that increase the likelihood of such behaviour.

The person must have some experience with the role to be adopted.

The enactment of the role must be rewarded.

But literature does not support that the conversion symptoms are a result of deliberate, conscious effort.

Socio-culture theory:Socio- culture theories are based on the supposed decrease in Conversion Disorders over the last century.

The decline is attributed to a more open attitude towards sexual desires.

Decline is also attributed to the greater psychological & medical sophistication which is more tolerant of anxiety than it is of dysfunctions that do not make

physiological sense.

Many studies have also supported the theory like-

Conversion symptoms are found to be more common among people of low socioeconomic status, people having less education level, and people having rural background.

Symptoms are found to be more common among people of underdeveloped countries.

Symptoms are found to be more common among conservative societies where frank expression of emotional distress is considered unacceptable.

Biological factors:Genetic factors have been proposed, but research does not support the theory.

Physiological factors that seem to have clear relation with the development of conversion disorder-

Conversion symptoms are more likely to occur on the left side of the body than the right side.

The majority of conversion symptoms, then, may be related to the functioning of right hemisphere of the brain.

Disconnection of two brain hemispheres surgically has shown that the right brain hemisphere can separately generate emotions, particularly unpleasant ones, more than does the left hemisphere and

hence responsible for conversion disorder.

Conversion symptoms thus can be neuro-physiologically linked to emotional arousal.

Right and left hemisphere of the brain is connected by corpus callosum. The left hemisphere has the verbal capacity to describe and explain emotions and thereby to gain awareness about them but this capacity is lacking in right

hemisphere and thus responsible for conversion disorder.

In Conversion Disorder, left hemisphere somehow blocks impulses carrying painful emotional content from the right hemisphere.

Thus the person with conversion disorder makes no connection between it and his troubling circumstances or his emotional needs.

Treatment:As most of the persons with Conversion disorder define their symptoms in physical terms, they go more often to physicians than to mental health professionals.

The ‘Talking Cure’ or ‘Free Association’ developed by Psychoanalysts is based on the assumption that a massive repression forces psychic energy to be converted into conversion symptoms, therefore,

Catharsis should be done. Which however have not been found to be very effective.

Many Behavioural therapeutic techniques are in use and found to be effective to some extend such as-

Systematic Desensitization. Family Therapy. Assertion Training.

Social Skill Training. In Vivo Exposure. Operant Training Feedback.

In many instances the best treatment

comes out to be no treatment at all but, rather the provision of support, reassurance and non threatening explanation of the causal factors.

Thanks !