Conversion Disorder (CD), also known as Functional Neurological Symptom Disorder is a psychiatric disorder where “one or more symptoms emerge quickly and affects [one’s] awareness, perception, sensation, or movement without any apparent physical cause” (American Psychiatric Association, 2015) and is listed under Somatic Symptom Disorders in the DSM-V. The DSM-V states that Conversion Disorder is diagnosed when one or more symptoms presented affect the normal functioning of bodily movements or sensations. There must not be a physiological cause upon in-depth medical review. The presented symptoms must also not be attributed to other medical conditions or mental disorders. These symptoms also inhibit the normal functioning of an individual such as in social or occupational contexts. Contrary to the DSM-V, the ICD-10 categorises Conversion Disorder under Dissociative Disorders instead of Somatoform Disorders, but the ICD-10 share a similar diagnostic criterion as the DSM-V.
The causes of Conversion Disorder are not clearly and understood in its entirety, but it is attributed to biological and psychological factors. Some common symptoms of Conversion Disorder include sudden unexplained paralysis, psychogenic non-epileptic seizures (PNES), difficulty swallowing, mutism and even blindness. In cases where patients were diagnosed with Conversion Disorder, no physiological factors could be attributed to the presenting symptoms. The presenting symptoms are real and distress-causing where individuals exercise no control over their symptoms; symptoms are not due to malingering but rather caused by psychological conflicts (Ali, Jabeen, Pate, Shahid, Chinala, Nathani, & Shah, 2015). One common consensus is that Conversion Disorder is the unconscious “conversion” or manifestation of emotional problems into physical complaints (Ali et al., 2015). Biological factors are thought to have played a significant role too, having a pre-existing medical condition or neurological illness such as epilepsy would make PNES a more prominent presenting symptom in individuals with Conversion Disorder (American Psychiatric Association, 2015). Conversion Disorder commonly presents itself during the course of other psychiatric disorders, particularly in depressive and anxiety disorders.
Epidemiology and Prevalence
A research found that almost a quarter of outpatients in neurological clinics presented symptoms of Conversion Disorder. In the context of general medicine, up to one-fourth of patients showed some symptoms of Conversion Disorder, but only 5% met the full diagnostic criteria to be diagnosed with Conversion Disorder (Feinstein, 2018). Conversion Symptoms affects both men and women but has been found to be more prevalent in females, during their young adulthood. Past research has shown that populations in rural areas and of lower socioeconomic status (SES) are more likely to be affected by Conversion Disorder. However, more research must be conducted to reaffirm these statistics (Feinstein, 2011). Conversion Disorder has been classified in the National Organisation of Rare Diseases (NORD) as a rare condition within the general population. Conversion symptoms are believed to be psychogenic, which is defined as symptoms that result from psychological factors. The APA states that psychogenic symptom(s) “refer[s] to a disorder that cannot be accounted for by any identifiable physical dysfunction and is believed to be due to psychological factors”.
History of Conversion and Somatic Symptom Disorders
The modern understanding of Conversion Disorder has been greatly influenced by the work of Sigmund Freud and Josef Breuer who coined the term ‘hysteria’. Freud proposed that such symptoms were an unconscious attempt of an individual to resolve internal conflicts. The failure to reconcile such conflicts led to the unconscious expressing them through physical means. These symptoms commonly have underlying messages that the unconscious is attempting to express. It is a symbolic representation of irreconcilable internal conflicts, unacknowledged memories, or repressed emotions. Freud also emphasised that the failure to confront traumatic experiences would cause a considerable amount of mental torment that it would be “converted” into physical symptoms, or what we would now know as psychogenic symptoms. Psychogenic symptoms are physical symptoms that are presented with no known physiological cause and, hence, are attributed to psychological and emotional components.
The case that would become a hallmark of Freud’s career was his treatment of ‘Anna O’ in Studies on Hysteria, Anna was first seen by Freud’s mentor and friend, Josef Breuer, for unexplained paralysis of her right arm and leg and abnormal speech. Anna was diagnosed with ‘hysteria’ by Breuer after he found that no physiological causes were present, it is believed that Anna was subsequently referred to and co-treated by Freud. However, whether or not Freud was directly involved in the treatment of Anna is contestable where some proponents suggest that Freud’s notes and hypotheses on Anna’s case were merely based on his study of Breuer’s case notes and not through his direct treatment of Anna.
What was mentioned in Studies on Hysteria was that Anna’s paralysis could have been possibly linked to her father’s illness and his eventual death due to Tuberculosis in 1880, where she took on the role as his caregiver when he was bed-bound. Breuer recalled a dream that Anna shared, where she witnessed a black snake approaching a bed-bound patient but was unable to protect the patient as she felt like she was completely paralysed. Anna noted feeling helpless and powerless.
Freud then associated this with her unexplained paralysis and linked it to her father’s illness where she acted as his caregiver but was severely restricted in what she could do to aid her father’s recovery. Freud concluded that her state of paralysis was due to her unresolved internal conflict of dealing with great amounts of frustration and helplessness in caring for her dying father. Therefore, this suggested that her symptoms were caused by ‘hysteria’ where her failure to confront and express traumatic experiences manifested into physical symptoms.
‘Hysteria’ in Females today
Freud theorised that ‘hysteria’ was an “exclusively female disease” (Tasca, 2012) because he saw women to be mentally weaker and easily affected by psyche and libidinal forces. This theory, however, was eventually abandoned by Freud himself in 1897 where he described his period of unhappiness as “my little hysteria” (Tasca, 2012) and carried on to elaborate that “The chief patient I am preoccupied with is myself” (Tasca, 2012). Despite this, ‘hysteria’ is still widely alluded to females today. In the past, some physicians and psychoanalysts believed that Conversion symptoms are cause by females having “hyposexuality” and “tendency to cause trouble for others” (Maines, 2001). In recent times, because of medical advances; psychologists, counsellors and psychiatrics are tremendously well equipped and sufficiently trained to perform their duty. Now ‘female hysteria’ has been shown to be wrong.
Freud was not the first who theorised the causes of ‘hysteria’. Most prominently Hippocrates, an Ancient Greek physician and philosopher wrote in his collected works Hippocratic Corpus, that he thought ‘hysteria’ symptoms were caused by women’s “wandering womb” (Gilman & Al, 1993).
Plato held similar believes and personified the phenomenon of the “wandering womb” as a living animal which roamed around the female body and obstructed the functioning of various organs, and hence resulting in the presenting symptoms (King, 2007). Common treatments at that time were often pseudo-scientific, from massaging a woman’s genital area, inducing sneezes to placing aromatic scents on the female genitals and placing foul smells to the lady’s nose. All of which were believed to help ‘shift’ the “wandering womb” back to its rightful position.
According to The British Library, one of the earliest recorded medical documentation of ‘hysteria’ was by an English physician Edward Jorden in 1603. He was the first physician who came forward in courts to defend women accused of witchcraft as he attributed ‘hysteria’ symptoms (then associated with witchcraft) to be a medical condition rather than evidence of witchcraft.
Influenced by the works of Freud, the American Psychiatric Association (APA) kept the term “hysteria” until the 1980s. Prior to then, Conversion Disorder was diagnosed as “Hysterical Neurosis- Conversion type”, and after the 1980s, the term “hysteria” was no longer used in the DSM. Most of the international psychiatric community agree that Conversion Disorder can emerge as a method of psychological defence, a defence mechanism invoked in the face of a perceived threat that the mind may deem too overwhelming for an individual to confront. With current advances in the medical field of radiology and brain imaging, researchers are studying how the human brain reacts when faced with a perceived threat. On the biological side, it is suggested that Conversion Disorder could be as a result of a “disorder in the circuits that govern the processing of sensory stimuli or voluntary actions” (Harvard Health Publishing, 2014). Research in this area remains in the primary phase and the exact causes of Conversion Disorder are not fully understood.
DSM-V noted that other than biological and psychological causes, factors such as personality and environment may also play a role in increasing one’s risk of getting Conversion Disorder. Individuals who often do not confront issues healthily, and individuals who tend to avoid confronting problems due to fear, are exposed to an increased risk of Conversion Disorder. Individuals who grew up in an abusive, unsafe, and neglectful environment were found to be exposed to a higher risk of Conversion Disorder. Although not invariably, the presence of recent strong stressor(s) or significant life event(s) is often a good qualifier of an increased risk of Conversion Disorder.
Psychologists today commonly associate Conversion Disorder to the Learning Theory. The Learning Theory proposes how children receive, process, and retain knowledge acquired during the learning process. It takes into account cognitive, environmental, affective, prior knowledge, behavioural factors, and how these make an impact on the process of learning in children. All of which would influence how children would come to understand and view the world, thereby affecting how they deal with situations in their lives (Ormrod, 2012).
Therefore, whichever means of coping that is picked up during childhood would by far and large be brought into one’s adulthood. For example, a child who is often told to “suck it up” whenever a conflicting situation arises may use silence as a coping mechanism. Such a coping method may translate into conversion symptoms such as conversion mutism where an individual is unable to speak under all circumstances. (differentiated from Selective Mutism which states that an individual would have the ability to speak under certain circumstances but not being able to do so in other situations).
Pharmacological Therapy and Psychiatric Interventions
Treatment of patients with Conversion Disorder is dependent on the presenting symptom(s) as treatment can range from physiotherapy to speech therapy. Above all, medications may be prescribed if the patient reports any issues such as anxiety and low moods. Physical examinations will be conducted by a physician, and they may include scans to ensure that any physical causes are ruled out. In some cases, psychological assessments like the MMPI-2-RF will be used.
SCID-5 (Structured Clinical Interview for DSM Disorders V) is a method of interview consisting of open and closed-ended questions posed by a trained physician to assess a patient for a psychiatric disorder based on the DSM-V. The SCID-5 encompasses cognitive, behavioural, and affective perspectives in its assessments (Xiong et al., 2017). The APA published the SCID-5-RV which included a “core” and “enhanced” configuration, within the modules; module J included Somatic Symptom Disorders, which Conversion Disorder is a part of.
ECT (Electro-Convulsive Therapy) has been suggested as a form of treatment for Somatic Symptom and Related Disorders (Lambert & Bergin, 2015). However, recent studies seemed to favour a more non-invasive form of treatment through the use of rTMS (repetitive Transcranial magnetic stimulation) which has shown some promising results to help reducing conversion symptoms as it addresses the neurophysiologic aspect of Conversion Disorder (Schönfeldt-Lecuona, Connemann, Viviani, Spitzer, & Herwig, 2006) . rTMS has been found to be especially effective for patients with conversion symptoms of weakness and paralysis (Schönfeldt-Lecuona et al., 2016).
Counselling and psychotherapy are also another prominent treatment method used for patients with Conversion Disorder as it seeks to address the emotional aspects of the conversion symptoms (Allin, Streeruwitz, & Curtis, 2005). The most prominent model being CBT (Ali et al., 2015 and Sharpe et al., 2018). Habiba-Jasmine (2017) successfully utilised CBT methods and interventions to treat cases of Conversion mutism. The study concluded that CBT was an effective model of therapy as it cured the mutism, with the patients reporting improved moods, reduced anxiety and depressive symptoms as well as the reduction of scores on their Social Interaction Anxiety Scale (SIAS) which was about 43 before treatment, which indicated high levels of social anxiety, down to 10 which marked slight social anxiety. Using CBT to treat Conversion Disorder has produced evidence to show an improvement in patients’ condition after being in 3 to 6 months of CBT sessions (Williams et al., 2017).
Psychotherapy is used as it helps individuals to resolve the inner conflict, which is considered to be a significant factor in causing conversion symptoms. However, the model used for patients can be subjective to the patient’s context, other models such as Hypnosis, Family Therapy and even Psychodynamic therapy has also been found to be useful in reducing conversion symptoms (Stonnington, Barry, & Fisher, 2016).
Regardless of which psychotherapy model is adopted, the aims will consist of altering how the brain processes information. The goal is to help patients express emotional distress through words and not through physical symptoms. Psychotherapy will strive to “break the established, unconscious pattern that leads to [conversion] symptoms” (O’Neal & Baslet, 2018).
Psychotherapists can also reassure patients that their conversion symptoms are not permanent. Typically, conversion symptoms are brief and would fade away spontaneously (Harvard Health Publishing, 2014). As conversion symptoms are psychogenic, psychotherapy addresses the psychological factor in patients with Conversion Disorder. It helps the patient to explore any problems that are causing distress and can even address deep-rooted issues that could be affecting the patient unconsciously. Through psychotherapy, patients are guided to confront their issues and not suppress it. This leads to increased self-awareness and allows the patients to have a more holistic view of the world and of their ‘self’. It equips patients with skills to tackle problems instead of triggering a coping mechanism that is dysfunctional in the long run.
As the causes of Conversion Disorder are attributed to emotional stress, anxiety, and trauma (Feinstein, 2011). Addressing the root cause would mean working on any issues that are causing distress (Owens & Dein, 2006). Therefore, such management of conversion symptom(s) will avoid symptomatic treatment where it focuses on eradicating only the physical symptoms but not the emotional distress which is believed to be a significant factor in causing conversion symptom(s). Hence, the most effective method would be combining both psychotherapy and symptomatic treatment. To illustrate, conversion paralysis can be prescribed physiotherapy as well as psychotherapy. This two-pronged approach encompasses both symptomatic treatment and psychological assessment and counselling.
Conversion Disorder has come a long way from just being termed “hysteria” and assumed to only affect females because of how it was thought that the womb wanders around the body. Now, we understand that it affects both genders and has a lot to do with how an individual perceives life situations and how they were taught to overcome them. Although we may not be consciously perceiving our every action because it can get exhausting, it will be good to note our thought processes during challenging circumstances. Understanding how we face difficult times can help us to identify healthy and unhealthy thought patterns.
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Contributor: Julian Anschel Lai Jang Ein
Julian is currently pursuing the Bachelor of Arts (Honours) Guidance and Counselling with Northumbria University. He is also a student member of APACS, actively contributing psychological articles.