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Jasmine Moxley

Dr. Erin Dietel-Mclaughlin

Multimedia Writing & Rhetoric

9 November 2012

Conviction in Conversion Disorder

Imagine going to bed one night and, right before closing your eyes, you glance around to

see your epic Bob Marley poster hanging right above your head, your acoustic bass posted up in

the corner, your favorite red colored walls, crazy cool star night covers and your mom standing

at the door saying goodnight. Then waking up the next morning to only see darkness? You’re

blind, all of sudden, no explanation and no way to fix it. You go to the doctor searching for

answers; they tell you nothing is wrong and that you are faking your blindness. How absurd!

You don’t know what’s happened and you can’t do anything to get better. All you get from your

doctor is “It’s all in your head and its up to you to fix this”. How can that be the only the

explanation!

The truth is that this is in no way the only explanation. Unfortunately, “20%-25% of

patients in a general hospital setting have individual symptoms of conversion” (Feinstein 916)

yearly, meaning they go through similar horrifying and confusing experiences like the

hypothetical above. Each situation varies in the finer details but they all share the same end

result: an apprehensive doctor and a questionable diagnosis. You may wonder now what these

“symptoms of conversion” are and the answer is simple. Today there exists a condition called

conversion disorder, a debilitating malady that causes the presence of physical illness.

“Symptoms” include but are not limited to, blindness, paralysis and the inability to speak

resulting from a psychological event (PubMed Health). The massive dilemma lies in the

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resistance of many in the medical community to recognize this disorder as a legitimate illness

(PubMed Health). This elusion then leads to misdiagnoses, confusion and unsuccessful

treatments, which end in both unhappy doctors and patients.

Recent research by Anthony Feinstein, Edgar Miller, T. Nicholson et al, Cynthia M.

Stonnington, John J. Barry, Robert S. Fisher has provided evidence to demonstrate that

conversion disorder is, in fact, a real and severely debilitating condition. Such discourse includes

actual patients that suffer from this affliction, unfeigned symptoms, successful treatments and

substantial studies conducted by other doctors who support the thesis behind the existence of

conversion disorder. In this essay, I will argue that conversion disorder is a viable concept, in an

effort to change the minds of those in the medical community that don’t believe in this

debilitating condition. A doctor’s attitude has an immense affect on a patient’s successful

recovery and for this reason belief is crucial.

To begin, we first must define conversion disorder. Edgar Miller identifies three

assumptions in his paper “Conversion Hysteria: Is it a Viable Concept?” He states that first;

symptoms come about without explainable pathological evidence. Second, these symptoms are

experienced in very real ways and are not “consciously feigned” (181), meaning these patients

do not intentionally fake their blindness, paralysis, numbness, etc. Third, psychological events

known more commonly as stressors are “transformed or ‘converted’” (181) into the physical

symptoms that these patients experience. Miller’s definition of conversion disorder follows

criteria similar to the diagnostic criteria found in The Diagnostic and Statistical Manual of

Mental Disorders. The DSM-IV is a manual designed to help medical professionals properly

diagnose their patients by standardizing how mental disorders are defined.

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What’s important to recognize here is the fact that conversion disorder is included in the

DSM-IV, thereby legitimizing its categorization as a mental disorder on paper within the medical

community. However some doctors still fail to wholly accept conversion disorder as a feasible

diagnosis for those suffering from any type of unexplainable neurological and/or sensory

malfunction. It is important to identify which doctors seem to associate themselves with those

doctors and which do not. In the article “Neurologists’ Understanding and Management of

Conversion Disorder” by Richard A Kanaan, David Armstrong and Simon Charles Wessely, a

postal survey study was conducted through a community of practicing consultant neurologists on

their understanding and management of conversion disorder. The final results provided helpful

information to understanding the dynamic of the medical community, specifically those

registered with the Association of British Neurologists in the UK.

It was found in this survey that many of the older neurologist agreed, “feigning was

entangled with conversion disorder” (Kanaan, David, Wessely 961). They believed, more or less,

that those who are considered to have conversion disorder fake their symptoms or perhaps it is

just near impossible to tell the difference between feigned symptoms and real ones. The younger

and female dominant group of neurologists believed that, one day, conversion disorder would be

recognized and understood neurologically and maintained better relationships with their

conversion patients now than those had in the past (961). It seems very cliché that the older

generation would serve as the unaccepting populous and the younger, foremost female

generation would do the exact opposite. I find it extremely interesting that the female group of

neurologists found their relationships with their conversion patients were much healthier than

those of the older, male orientated group. Reiterating my point that belief is a crucial factor of

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patient care, a more positive doctor-patient relationship stemming from a doctor who believes in

his/her patient’s condition surely results in positive outcomes.

I understand that the older doctors have a hard time accepting conversion disorder in

their patients on the basis of false symptoms, but one must know that some symptoms can not be

faked and it’s immensely important to recognize which patients are not feigning but suffering

from symptoms. Miller says because there is no absolute way to see in another’s mind there is no

one hundred percent way to guarantee whether or not a patient is “faking it” but he claims there

are two sources of evidence that allow doctors to make reliable conclusions. The first “concerns

the ability of professionals to distinguish known dissimulators from those who are presumably

honest” (184). I believe a good doctor should be able to pick up some kind of sign that points

towards honesty and dishonesty, so they shouldn’t really have a problem making use of this first

source. The second source “is based around studies of whether patients regarded as having

hysterical symptoms behave in ways differently from what might be expected [from those who

deliberately dissimulate or malinger]” (184). A well-matured neurologist/psychologist who has

spent decades of his/her life dedicated to the study of the human brain can be expected to have

had enough patients in their past to decipher between a patient who intentionally attempts to

dissimulate symptoms and one who does not.

It seems that the older generations of doctors should be the ones who have an easier time

communicating with their conversion patients, not the younger ones. They have had much more

experience and therefore it should not be acceptable in any way for them to simply brush off a

diagnosis because they believe it’s “impossible” to tell the difference between real and fake

symptoms. There is a way to at least attempt to find the real population of suffering conversion

patients; the young female neurologists seem to be successful in doing just this.

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Diagnosing a patient with conversion disorder is tricky. The condition isn’t even

considered until all other possible explanations are ruled out. The problem with this type of

diagnosing strategy is that as Feinstein says “excessive investigation carry an iatrogenic risk and

may prolong a patient’s symptoms” (917). This means that a patient who is suffering from

conversion disorder will continue to suffer because of the way doctors now diagnose patients

and/or doctors may be unwilling to accept that conversion disorder is the answer so they order

excessive amounts of testing, which prolongs symptoms. Not all doctors’ cause their conversion

patients harm for those reasons. Some doctors may be attempting to find a solution that has a

more definite treatment path so their patient in the long run will be much better off. Feinstein’s

article offers the criteria box from the DSM-IV to specifically diagnose conversion disorder

(916).

There are six points to consider as a doctor in this situation. One, patients must present at

least one symptom that affects his/her motor system involuntarily – this may be displayed

through numbness, paralysis and/or convulsions/seizures. Two, psychological factors seem to be

connected to the symptoms. For example, symptoms may become worse when the stressor is

present. Three, symptoms cause the patient to feel distress or discouraged during important

activities and may invite medical concern. Four, if a patient seems to be faking his/her illness,

then other disorders should be considered. Munchhausen Syndrome is an example of people

deliberately feigning their illness for the sole of reason of being a sick, attention-seeking

individual. Malingering is another type of feigning with a different reason; individuals who

malinger have external motives such as monetary gain, avoiding criminal punishment, etc. Five,

an extensive investigation is conducted and no explanation can 100% explain the cause of the

symptom(s) and six, not only can no other condition better explain the reason behind deficits but

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also the deficit should not be limited to solely sexual function and/or pain. (916) There overall is

a lot to consider during the process of diagnosing a conversion patient.

What worries doctors is the accuracy behind their diagnoses and this explains most of the

apprehension behind confidently proclaiming that their patient suffers from conversion disorder.

In the survey conducted by Kanaan, Armstong and Wessely, only 16% of neurologist could say

they confidently diagnose their patients (963). Feinstein article states “33% of patients diagnosed

with hysteria about 10 years earlier subsequently received a different diagnosis that could

explain their initial symptoms”(917). I understand how this can happen. My mother was recently

diagnosed with Trigeminal Neuralgia (TN), a condition in the brain that causes extreme cranial

pain due to a decaying of the myelin sheath around the trigeminal nerve in the brain, the biggest

nerve in the body (PubMed Health). Ten years ago, the symptoms associated with this disease

were thought to be caused by conversion disorder. The patients then suffered from what is

deemed by Ben Carson as “the most excruciating pain on the planet”, with unsuccessful

treatments and unhelpful doctors who believed that conversion disorder was a disease made up in

ones head and so one was faking his/her excruciating pain. This disease was, and still is, called

the Suicide Disease because patients could not find relief from the pain through any kinds of

psychological treatment and/or medication and decided that committing suicide was the only

way to end the suffering (Sarmah).

Examples like this serve as a very good reason why some doctors may be unwilling to

dedicate themselves to say that a patient suffers from conversion disorder. However, it is

extremely crucial that we examine the patient’s mental health in this situation to further

understand how a doctor’s attitude influences his/her patient. Many patients found suicide their

only option for relief. The majority of these suicide patients felt they were alone in the world and

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nothing could help them (Sarmah). Such patients included a young man by the name of John

Kerkemeyer, who was diagnosed at the age of 22 with TN. Kerkemeyer describes his pain “like

someone taking electric shock to your mouth and yanking your mouth sideways at the same

time” (Sarma). Kerkemeyer says he didn’t want to eat, open his mouth, talk or do anything. Such

severe pain with no functional solution robbed him of his 20’s. This disease drastically changed

Kerkemeyer’s life, as it does to many of its victims.

Doctor patient relationships influence a patient’s mindset tremendously. If the doctors

perhaps had taken the diagnosis of conversion more seriously, believing in the condition instead

of accusing the patient of self-inflicted misery. Then perhaps the patients would have lived long

enough to discover that their condition was not just conversion disorder. They could have

discovered that there were ways to treat the excruciating symptoms. The belief in conversion

disorder may have saved lives, long enough at least for individuals to receive the actual help they

required. Though the diagnoses may have been a mistake, belief in a patient’s suffering caused

by an external source instead of an internal one is what mattered then and what matters now.

Treatments when dealing with conversion disorder are a sensitive process. The timing

involved with telling a conversion patient of his/her diagnosis is crucial. Discussion of a patient’s

diagnosis before it is confirmed may upset the patient in a way that can hinder his/her healing

process. Many patients suffer from intensely traumatic psychological backgrounds; upsetting the

patient even more will not contribute to a good prognosis. Once the patient has been informed

appropriately of his/her illness, a wide array of treatment options may be offered. An article

found in The American Journal of Psychiatry, “Conversion Disorder”, written by Cynthia

Stonnington, John Barry and Robert Fisher, offers four different types of treatments that have

resulted in positive outcomes. The first type of treatment is psychotherapy, usually offered to a

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patient that has been suffering from unbearable and/or fearful symptoms that “are maintained by

a ‘vicious circle of behavioral, cognitive, affective, physiological and social factors’ (50)”(3).

Because these symptoms are nurtured by many living factors, a number of specific techniques of

psychotherapy are used and these include: exposing the patient gradually to their fears, having

them practice problem solving techniques in these situations to confront their fears, and

refraining from succumbing to their misled cognitive beliefs about their condition and the

powerlessness they may feel when it comes to control over what is happening to their bodies. In

the event that psychotherapy does not work, some other therapies include hypnosis,

pharmacotherapy and trans cranial magnetic stimulation. Details on these specific therapies can

be found on pages three and four of Stonnington, Barry and Fisher’s article.

In the case of real life patients such as “Ms. A” (Stonnington, Barry, Fisher) and little

“Suzi” (Lupu) most of the conversion treatments offered resulted in a good prognosis for both

patients. “Ms. A” participated in pharmacotherapy and, after being given a prescription for

aripiprazole, she was reported to have “improved energy, focus and concentration and said that

she felt less overwhelmed with everyday stress” (Stonnington, Fisher, Barry 2). Though the

medication did not help with her head tremors, hypnosis did and with its proper use she

successfully eliminated her head bobbing. Little “Suzi’s” doctors prescribed a placebo

medication in attempts to eradicate her conversion symptoms. After being given the placebo,

“Suzi” seemed to improve and many doctors in the medical community would like to use this as

an example of how conversion disorder is not real because a false treatment seemed to improve

“Suzi’s” condition. However, these doctors fail to take into account that after, and partly during,

“Suzi’s” medication regimen, she was also given psychotherapy and hypnotherapy, which can

also account for the improvement in her condition. Real types of treatments improved a very real

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type of disorder. The false treatment doesn’t discredit the viability of conversion disorder instead

it solidifies the values behind a seemingly trustworthy doctor who “attempts” to offer resolution

to his/her patients. “Suzi” believed that her doctor was offering a real treatment and it yielded

real results. Stonnington, Fisher and Barry’s article found that “between 50% and 90% of

patients with conversion disorder exhibit short-term resolution of symptoms after reassurance”

(5). A patient’s perception of how he/she is being treated and what it means to be healthy

thereby greatly influences his/her medical outcomes.

If the information given above wasn’t enough to convince those who question the

validity of conversion disorder, there also exists physical evidence in the brain that this condition

can severely affect its victims. Feinstein’s article offers a study that “showed reduced volumes of

the right and left basal ganglia and right thalamus relative to people without the disorder” (918),

which means that people with conversion suffer from actual changes in their brain when

compared to those who are “healthy”, deficits are not simply theoretical. A picture of one of the

functional MRI’s can be seen below with a caption to explain the photo’s significance (Figure 1).

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Feinstein found that the results of the MRI study may “suggest that patients with conversion

disorder have an abnormal pattern of cerebral activation in which limbic areas (or areas richly

connected to the limbic system) override the activation of the motor and sensory cortices” (918)

so the results serve as proof that conversion patients aren’t voluntarily causing symptoms, the

response is involuntary. This response is a result of “a mechanism called ‘reciprocal inhibition’

[which] allows each region to shut off the other during the processing of information” (918).

This can explain how conversion disorder is related to psychological stress. While the brain tries

to process a significant traumatic event, another part may cease to function, allowing the brain

access to more energy to expend toward processing the stressor.

Another structural MRI study conducted by T. Nicholson et al. showed similar results.

Conversion patients demonstrated reduced bilateral thalamic volume, reduced intracranial

volume and reduced volume to the left but not the right lentiform nucleus. These physical

changes found in the brain correlated to the evidence of thalamic volume reductions found in

patients who had suffered limb amputation. This similarity built a connection between the level

of limb disuse in an amputee patient who had lost his/her limb and therefore could not use it and

a conversion patient who experienced similar problems of limb disuse even though he/she still

has his/her limb. This connection serves as a strong indicator of the severity of conversion

disorder, which provides an extremely strong basis for the viability of conversion disorder to be

widely accepted in the medical community.

I propose that more studies be conducted, both MRI studies and case studies of patients

like Ms. A and Suzi. These studies will provide more physical evidence, such as that found in the

brain. Along with MRI and case studies, surveys conducted on the basis of beliefs found in the

medical community may provide some with the only type of discourse they can trust if they

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follow the motto “If I see it, I can believe it”. The important thing is that we get those doctors on

the right track to beginning to reassure their patient. Restoring confidence to the patient is key to

the healing process. Reassurance goes hand in hand with confidence. Confident doctors supply

confident diagnoses, which will not only avoid misdiagnosing patients but also avoid

excessive/unnecessary testing and extended periods of uncertainty,s therefore eliminating longer

periods of patient suffering. Better communication will also result in better patient care. I

believe these changes are necessary to ensure that conversion patients find healing in some form

or another. We as a community either provide victims of conversion with the disposition they

require or they will continue to live in the misery they have been subjected to for all these past

years.

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Works Cited

Conversion Disorder MRI: Figure 1. Academic Search Premier. N.p., n.d. Web. 2 Nov. 2012.

Feinstein, Anthony. "Conversion Disorder: Advance in Our Understanding." Canadian Medical

Association Journal 183.8 (2011): 915-20. Academic Search Premier. Web. 2 Nov. 2012.

Lupu, Viorel. "Cognitive-Behavioral Therapy in the Case of a Teenager with Conversion

Disorder with Mixed Presentation." Journal of Cognitive & Behavioral Psychotherapies

5.2 (2005): 197-205. Academic Search Premier. Web. 2 Nov. 2012.

Miller, Edgar. "Conversion Hysteria: Is It a Viable Concept?" Cognitive Neuropsychiatry 4.3

(1999): 181-91. Academic Search Premier. Web. 2 Nov. 2012.

"Neurologist' Understanding and Management of Conversion Disorder." Journal of Neurology,

Neurosurgery and Psychiatry 82.9 (2011): 191+. Expanded Academic ASAP. Web. 2

Nov. 2012.

Nicholson, T., et al. "A Structural Mri Study of Motor Conversion Disorder: Evidence of

Bilateral Reduction in Thalamic Volume." Journal of Neurology, Neurosurgery &

Psychiatry 83.10 (2012): 11+. Academic Search Premier. Web. 2 Nov. 2012.

PubMed Health. National Center for Biotechnology Information, U.S. National Library of

Medicine, 23 Nov. 2010. Web. 30 Oct. 2012.

<http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001950/>.

Sarma, Satta. "Nerve Disorder's Pain so Bad It's Called the 'Suicide Disease'." Medill Reports

Chicago [Chicago] 28 Feb. 2008: n. pag. Web. 5 Dec. 2012.

<http://news.medill.northwestern.edu/chicago/news.aspx?id=79817>.

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Stonnington, Cynthia M., John J. Barry, and Robert S. Fisher. "Conversion Disorder." American

Journal of Psychiatry 163.9 (2006): 1510-7. ProQuest. Web. 2 Nov. 2012.

The Trigeminal Neuralgia Center at Johns Hopkins. YouTube. N.p., 18 Oct. 2012. Web. 5 Dec.

2012. <http://www.youtube.com/watch?v=0UF2AB03Sq8>.