CONVERSION DISORDER

CONVERSION DISORDER The Case of Anna O.nna O. was the pseudonym of a patient of Josef Breuer, who published her case study in his book Studies on Hysteria, written in collaboration with Sigmund Freud. Her real name was Bertha Pappenheim (18591936), an Austrian-Jewish feminist and the founder of the Jdischer Frauenbund (League of Jewish Women).

Anna O. was treated by Breuer for severe cough, paralysis of the extremities on the right side of her body, and disturbances of vision, hearing, and speech, as well as hallucination and loss of consciousness. She was diagnosed with hysteria. Freud implies that her illness was a result of the resentment felt over her father's real and physical illness that later led to his death.[1]

Her treatment is regarded as marking the beginning of psychoanalysis. Breuer observed that whilst she experienced 'absences' (a change of personality accompanied by confusion), she would mutter words or phrases to herself. In inducing her to a state of hypnosis, Breuer found that these words were "profoundly melancholy fantasies...sometimes characterized by poetic beauty". Free Association came into being after Anna/Bertha decided (with Breuer's input) to end her hypnosis sessions and merely talk to Breuer, saying anything that came into her mind. She called this method of communication "chimney sweeping", and this served as the beginning of free association.

Historical records since showed that when Breuer stopped treating Anna O. she was not becoming better but progressively worse.[2] She was ultimately institutionalized: "Breuer told Freud that she was deranged; he hoped she would die to end her suffering".[3]

She later recovered over time and led a productive life. The West German government issued a postage stamp in honour of her contributions to the field of social work.[4]

According to one perspective, "examination of the neurological details suggests that Anna suffered from complex partial seizures exacerbated by drug dependence."[5] In this view, her illness was not, as Freud suggested, psychological, but neurological. While some believe that Freud misdiagnosed her, and she in fact suffered from temporal lobe epilepsy, and many of her symptoms, including imagined smells, are common symptoms of types of epilepsy, others meticulously refute these claim2Somatic symptom and related DisordersConversion disorder (Functional neurological symptom disorder)Illness anxiety disorderSomatic symptom disorderPsychological factors affecting other mental conditions

Made on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms)rather than the absence of a medical explanation for somatic symptoms.

A broad group of illnesses with bodily signs and symptoms as the predominant focus, influenced by the psyche Concept of mind/body interactions, with signals from the brain (?mechanism) indicating a problemNot based on theoretical construct or laboratory findings-no significant substantiating data, yet vigorous and sincere complaints not imaginary

Somatic symptom DisordersA disturbance of bodily function not conforming to current concepts of neurological anatomy and physiology:Characterized by the presence of one or more neurological symptoms, unexplained by a known neurological or medical disorder;Typically occurring in a setting of stress, and producing considerable dysfunction;Requiring for diagnosis the association of psychological factors, present at the initiation or exacerbation of symptoms.Conversion DisorderDefinitionAn illness of symptoms or deficits affecting voluntary motor or sensory functions, suggesting another medical condition, but judged due to psychological factors because of preceding conflicts or other stressors.Symptoms or deficits are not intentionally produced, not due to substance, and not limited to pain or sexual symptomatology.Gain is primarily psychological, and not social or monetary or legal. The term "conversion" is widely applied to some of these disorders, and implies that the unpleasant affect, engendered by the problems and conflicts that the individual cannot solve, is somehow transformed into the symptoms. In the Middle Ages, hysterical symptoms were attributed to demonic influences.

During the Renaissance, hysteria returned to medicine, being considered a somatic disorder by physicians, who implied a connection or pathway between the uterus and the brain.

Charcot described the classic form as la grande crisehystrique, which included phases such as the prodromal, epileptoid, trance, and terminal or verbal phases. He also proposed the term functional lesion.

Freud and Breuer jointly reported the first case of hysterical conversion, the case of Anna O.

Freud named this process somatic compliance or conversion

Conversion DisorderHistory1951 Conversion reaction.1968 Hysterical neurosis.1980- Conversion Disorder.2013- Functional neurological symptom disorder.

F44.4-F44.7 Dissociative disorders of movement and sensationDissociative motor disordersDissociative convulsionsDissociative anaesthesia and sensory lossConversion DisorderComparative NosologySome symptoms, but not severe enough to warrant diagnosis in 1/3 of general population at some time

Lifetime risk by some studies of 33% for either transient or longer-term disorder

25-30% of admissions to hospitals, 5% of neurology referrals.

Range in general population of 11-300/100,000

Incidence 0f 2-5/100,000/ yr

Conversion DisorderEpidemiologyRatio of women to menRange of 2/1 to 10/1 in adultsIncreased female predominance in childrenSymptoms in women more common on left side of body.Women with conversion symptoms more likely to subsequently develop somatization disorder.Association in men between conversion disorder and histrionic, dependent, avoidant and antisocial personality disorder.Conversion DisorderEpidemiologyOnset at any age, but most common in late childhood to early adulthood (rare before 10 years of age, or after 35, but reported as late as the ninth decade of life)Probability of occult neurological or other medical condition high with onset of symptoms in middle or old age.

Conversion DisorderEpidemiologyCommon PrototypesRural populationsDeveloping nations and regionsPersons with limited education and medical knowledge, or decreased IQLower socioeconomic groupsMilitary personnel exposed to combatIncreased Frequency Relatives of probands with conversion disorderMonozygotic, but not dizygotic, twin pairs

Conversion DisorderEpidemiologyConversion DisorderEpidemiologyCultural norms are important considerations The form of conversion may reflect cultural ideas about acceptable ways to express distress (e.g. falling, or an alteration of consciousness)Behaviors resembling conversion or dissociative symptoms are aspects of certain culturally sanctioned religious and healing ceremoniesCommon Axis I psychiatric conditions:Depressive disorders (increased suicide risk)Anxiety disordersSomatization disordersConversion in schizophrenia reported but considered uncommon, yet to admissions to a psychiatric unit for conversion disorder have significant mood disorder or schizophrenia.

Personality Disorders5 to 21% histrionic9 to 40% boderline/dependentAntisocial

Medical and especially neurological disorders occur frequently, with elaboration of symptoms stemming from original organic lesion

Conversion DisorderComorbidityMultidimensionalPsychoanalytic FactorsLearning TheoryBiological FactorsConversion DisorderEtiologyPsychoanalytic FactorsRepression of unconscious intrapsychic conflict (instinctual impulse, e.g. aggression/sexuality, and prohibitions of expression)

Conversion of anxiety into a physical symptom-the symptom binds anxiety

Symptoms allow partial although disguised expression of the forbidden wish or urge, such as to avoid conscious confrontation with the unacceptable impulses

The conversion disorder symptom has symbolic relation to the unconscious conflict (e.g. vaginismus with sexual desire, syncope with arousal, paralysis with anger)

The individual may derive secondary gain, with symptoms serving as a nonverbal means of controlling or manipulating others

Conversion DisorderEtiologyLearning TheoryConversion disorder considered as piece of classically conditioned learned behaviorSymptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation.Conversion DisorderEtiologyBiological FactorsBrain imagingHypometabolism of dominant hemisphereHypermetabolism of nondominant hemisphere? Impaired hemispheric communicationCorticofugal feedback? Excessive cortical arousal setting off negative feedback loops between the cortex and reticular formation w/ inhibitionNeuropsychological testsSubtle cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attentionIncreased incidence with head trauma/organicity

Conversion DisorderEtiologyDSM-V limits to those symptoms that affect a voluntary motor or sensory function (i.e. neurological symptoms)Conversion DisorderDiagnosisA. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

C. The symptom or deficit is not better explained by another medical or mental disorder.

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

DSM 5 CriteriaSpecify symptom type:(F44.4) With weakness or paralysis(F44.4) With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gaitdisorder)(F44.4) With swallowing symptoms(F44.4) With speech symptom (e.g., dysphonia, slurred speech)(F44.5) With attacks or seizures(F44.6) With anesthesia or sensory loss(F44.6) With special sensory symptom (e.g., visual, olfactory, or hearing disturbance)(F44.7) With mixed symptoms

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

Conversion DisorderDSM-IV-TR CriteriaMost common symptomsParalysisBlindnessMutismConversion DisorderClinical FeaturesSensory symptomsAnesthesia and paresthesia common, especially in extremities (although all sensory modalities can be involved)Distribution of the neurological deficit inconsistent with either central or peripheral neurological disease (e.g. stocking-and-glove anesthesia, and hemianesthesia beginning precisely along the midline) Possible involvement of organs of special sense (deafness, blindness, tunnel vision)Unilateral or bilateralIntact sensory pathways by neurological exam (e.g. conversion disorder blindness: ability to walk around without collision or self-injury, with pupils reactive to light, and normal cortical evoked potentials.)

Conversion DisorderClinical FeaturesMotor symptomsAbnormal movements (gait disturbance, weakness/paralysis) Movements generally worsen with calling of attention Possible gross rhythmical tremors, chorea, tics, and jerksAstasia-abasia (wildly ataxic/staggering gait, gross irregular/jerky truncal movements, thrashing/waving of arms-rare falls w/o injury)Paralysis/paresis involving one, two, or all four limbs (w/o conformation to neural pathways) Reflexes remain normalNo fasciculations/muscle atrophy (except chronic conversion)Normal electromyography

Conversion DisorderClinical FeaturesSeizure symptomsPseudoseizuresDifferentiation from true seizure difficult by clinical observation alone1/3 of those with pseudoseizures have coexisting epileptic disorderTongue biting, urinary incontinance, and injuries after falling can occur (although generally absent)Pupillary and gag reflexes retainedNo post seizure increase in prolactin concentrationConversion DisorderClinical FeaturesAssociated psychological symptomsPrimary gainSecondary gainLa belle indifferenceIdentificationConversion DisorderClinical FeaturesAssociated psychological symptomsPrimary gainInternal conflicts remain outside awarenessSecondary gainTangible advantages and benefits as a result of being sick (excuses from obligations and difficult situations, support and assistance otherwise not forthcoming, control of behavior of others)Conversion DisorderClinical FeaturesAssociated psychological symptomsLa belle indifferenceInappropriate cavalier attitude toward serious symptoms (lacking in some, but also in other seriously ill medical patients with stoic attitude-inaccurate determinant of conversion disorder)IdentificationUnconscious modeling of symptoms after someone considered important to the patientWith pathological grief reaction, bereaved persons commonly have symptoms of the deceased

Conversion DisorderClinical FeaturesNo specific standard laboratory testsAbsence of positivetests supports diagnosisExperimental psychophysiologyUnique sympathetic nervous system response as measured by skin conductance upon anxiogenic stimulusMore rapid cortical evoked potential spikes in contralateral sensory cortex upon physical stimuli

Conversion DisorderClinical Features The most important conditions in the differential diagnosis are neurological or other medical disorders and substance-induced disorders.Conversion DisorderDifferential DiagnosisConcomitant or previous neurological disorder or a systemic disease affecting the brain reported in 18% to 64% of cases of conversion disorder25% to 50% of cases classified as conversion disorder eventually receive diagnoses of neurological or nonpsychiatric medical disorders

Conversion DisorderDifferential Diagnosis7-11 year follow up of 99 patients: 22 (30%) of 73 available subjects had organic illness accounting for presenting symptoms initially diagnosed as conversion (Slater ETO, Glithero E J. Psychosom Res, 1965;9:9-13).

2.5-10 year follow up of 24 patients discharged form the neuroscience services of a teaching hospital with diagnosis of conversion: 5 (21%) of 24 with diagnosable neurological disease (Gatfield PD, Guze SB. Dis Nerv Syst, 1962;23:623-31).

6-12 month follow up of 50 patients discharged from the neurology service of a teaching hospital with conversion in differential diagnosis: 7 (14%) found with organic illness and 3 (6%) with hysterical elaboration of organic pathology (Raskin M, Talbott JA, Meyerson AT. JAMA, 1966;197:530-4).

64 patientswith diagnosis of conversion by psychiatric consultation service followed for an average of 3.3 years: 8 (13%) with organic illness (Stefansson JG, Messina JA, Meyerowitz S. Acta Psychiatr Scand, 1976;53:119-38).

Conversion DisordersDifferential DiagnosisNeurological/medical disordersDementia and other degenerative disordersBrain tumors, subdural hematomaBasal ganglia disease, myasthenai gravis, multiple sclerosisPolymyositis, acquired myopathiesOptic neuritisPartial vocal cord paralysisAcquired myopathiesGuillain-Barre, Creutzfeldt-Jacob, periodic paralysisAIDS (early neurological manifestations)Systemic lupus erythematousIdiopathic and sarcoma-induced osteomalaciaAcquired, nereditary, and drug-induced dsytoniasConversion DisorderDifferential DiagnosisPsychiatric disordersSchizophrenia Hallucinations presenting with conversion disorder generally present w/o other psychotic symptoms and often involve more than one sensory modality w/ vague or fantastic content.Depressive disordersAnxiety disorders Consider high anxiety states with phobia and panic attack associated with somatic complaints (e.g. difficulty swallowing)Dissociative disorders Dual diagnosis possibleConversion DisorderDifferential DiagnosisSomatization disorderIncludes possible sensorimotor symptoms, but chronic coarse beginning early in life involving many other organ systemsHypochondriasisNo actual loss or distortion of functionChronic somatic complaints, not limited to neurological symptoms, with characteristic attitudes and beliefs (disease phobia)Body dysmorphic disorder Imagined or slight defect in appearance, with no voluntary motor or sensory dysfunctionPain disorder-symptoms limited to pain (solely psychological) Sexual dysfunction-symptoms limited to sexConversion DisorderDifferential DiagnosisMalingering and factitious disorderSymptoms under conscious, voluntary controlHistory with malingering usually more inconsistent and contradictory than with conversion disorderFraudulent behavior clearly goal directed with malingeringConversion DisorderDifferential DiagnosisSymptoms probably the result of conversion disorder if resolved by suggestion, hypnosis, or parenteral amobarbital or lorazepam.

Conversion DisorderDifferential DiagnosisConversion DisorderDistinctive Physical FindingsCONDITIONTESTTunnel visionVisual fields

Profound monocular blindnessSwinging flashlight sign (Marcus Gunn)Binocular visual fieldsSevere bilateral blindnessWiggle your fingers; Im just testing coordination.Sudden flash of bright lightLook at your hand.Touch your index fingers.Conversion DisorderDistinctive Physical FindingsCONDITIONTESTAphoniaRequest a coughIntractable sneezingObserveConversion DisorderDistinctive Physical FindingsCONDITIONTESTComaExaminer opens eyesOcular cephalic maneuverSyncopeHead-up tilt testConversion DisorderDistinctive Physical FindingsCONDITIONTESTAnesthesiaMap dermatomesHemianesthesiaCheck midlineAstasia-abasiaWalking, dancingParalysis, paresisHand drop onto faceHoover testCheck of motor strengthInitial symptoms resolve within a few days to < a month in 90 to 100% (95% remit spontaneously, usually by 2 weeks)75% have no further episodes, with 20-25% recurring within a year during periods of stress25 to 50% present later with neurological disorders or nonpsychiatric medical conditions affecting the nervous systemConversion DisorderCourse and PrognosisPredictors of good prognosisSudden onsetEasily identifiable stressorGood premorbid adjustmentNo comorbid psychiatric or medical disordersNo ongoing litigationShort duration Short interval between onset and initiation of treatmentAbove average intelligenceParalysis, aphonia, blindness (tremor and seizures-poor prognosis)Conversion DisorderCourse and PrognosisAcute casesReassurance/appropriate rehabilitation Resolution usually spontaneousAbreaction, by which repressed material, particularly regarding a painful experience or a conflict, is brought back toconsciousness.

PsychotherapyA relative contraindication

Conversion DisorderManagement/TreatmentChronic cases Aggressive therapy of comorbid psychiatric illnessPharmacotherapyAnxiolytic or antidepressant medications ?Amobarbital interview?Psychotherapy?Conversion DisorderTreatmentPsychotherapyInsight-oriented supportive or behavior therapyRelationship with a caring and confident therapist most important feature of the therapyConfrontation re symptoms being imaginary detrimentalSuggestion of focus on stress and coping sometimes helpful for those resistant to idea of psychotherapyPsychodynamic approachesExploring intrrapsychic conflicts, and the symbolism of conversion symptoms ???

Conversion DisorderManagement/TreatmentThank you