Conversion Disorders in Mental Health Care-A Basic Review of Literature

Aga Khan University School of Nursing & Midwifery, Pakistan

Corresponding Author: Sarmad Muhammad Soomar * Aga Khan University School of Nursing & Midwifery, Pakistan.

Received Date: May 13, 2019

Published Date: Jul 4, 2019

Citation: Soomar SM. (2019). Conversion Disorders in Mental Health Care – A Basic Review of Literature. Mathews J Psychiatry Ment Health 4 (1): 23.

ABSTRACT:

Mental health issues have been grown with time and various diagnoses are explored. Conversion disorders are becoming prevalent mental health disease with time. The paper will provide a snapshot view to the readers about this disorder. The details extracted from different articles as a basic review includes definition, criteria, prevalence, etiology, signs and symptoms and the options for better management in clinical setup.

Keywords: Conversion; Hysteria; Mental Health; Disease; Neurology.

INTRODUCTION

A Disturbance in individual’s cognition, emotion or behavior may reflect any kind of mental disorder. Today, majority of population is dealing with some sort of mental illness for instance the most common; depression. All doctors must have experienced patients whose manifestations they can’t clarify. Those patients frequently incite despondency and disappointment, lacking physical explanation for their symptoms [1]. In psychiatry such symptoms are categorized under the umbrella of Somatoform Disorders, which incorporates a wide range of diagnosis, and one of these diagnoses is Conversion disorder; which traces its origin from Freud’s Psychoanalytical etiology. In other terms, Conversion disorder is the presence of neurological symptoms in the absence of neurological diagnosis or it’s a way of describing emotional or psychological crisis in physical ways [2]. These phenomena of bodily exhibition of signs has been known since antiquity, formerly known as hysteria, but was popularized by Freud who believed that anxiety resulting from any unconscious conflicts is converted into physical symptoms to find expression [3].

Taking a closer look at its historical background, term Hysteria derived from ancient Greek meaning uterus. It is referred to the uterus roaming in female’s body and causing symptoms as it moved. Hysteria was confined only to women at first; also it was mistaken for various bodily diseases. After the World War II males were also found, to be affected with hysteria. The term Hysterical neurosis was used in the Diagnostic and Statistical Manual (DSM - II) of mental disorders. But the transition led to removal of this term in order to classify disorder based on clinical phenomenology. It was categorized under somatoform disorder in DSM IV [4] and recently renamed as function neurological disorder, with function referring to a symptom without organic cause [5]. The primary characteristic feature of conversion disorder is impaired motor or sensory functions as explained in DSM-V, as “Conversion Disorder / Functional Neurological Symptom Disorder”. It is generally concerned with physical malfunctioning for instance impaired vision or difficulty speaking also known as aphonia without locating any pathology. Furthermore, it includes loss of sense, touch and not speaking in certain situations. Moreover, people also have seizures called nonepileptic seizures of psychogenic origin. Globus hysterics is the other most common symptom in which an individual feels a lump in throat making it difficult to swallow, eat or talk [6].

But the question arises here, that what could possibly account for somebody going visually impaired when all visual process are normal or encountering loss of movement of arms and legs when there’s no single clue of neurological damage. This is surprising yet an interesting phenomenon gained my attention while studying the personality theories proposed by Sigmund Freud, which pushed me towards writing an article on it, to understand how it happens and how people in developing countries are affected by it.

Prevalence

Conversion disorder is regarded as the commonest diagnostic problem encountered by psychiatrists of developing countries. In Pakistan it was reported to be representing 12.4% and 4.8% of the admissions in Inpatient and outpatients psychiatric units in 2007, while in India 31% of admissions was reported, and 27.2% cases were reported in Turkey [7]. It most commonly affects adolescents and young adults [8]. Moreover, most of the studies reported higher prevalence in females than males belonging to lower income group and having less education [7]. Still there’s little statistical information available while there’s plenty of studies on distressing life events preceding depression, I recognized very few studies of these distressing life events in regard of conversion disorder. However, the overall conversion disorder estimated around 50 per 100,000 [9].

Theoretical perspective

This controversial disorder has been attributed to various mechanisms but the most influential dates back to 19th century in times of Sigmund Freud. His psychoanalytical approach is described in four processes essential to the development of conversion disorder [10, 11]. The very first, the patient experiences a distressing event which is highly unacceptable and unconscious. Second, the conflict and preceding anxiety is unacceptable, the person represses the conflict in order to make it unconscious. Third, the anxiety continues to increase and becomes a threat to physical or psychological well-being, it converts into physical symptoms. This channeling of emotional arousal into bodily signs relives the pressure directly, dealing with the conflicts which are regarded as the primary gain. Fourth, As a result, physical symptoms often benefit the person by receiving increased attention and sympathy from others and avoiding difficult task in that situation which is considered as secondary gain. This behavior continues until the underline issue is resolved. An alternative explanation comes from the sociocultural theorists. The conversion disorder is thought to occur in cultures with strict social frame works that keep people from communicating their sentiments and feelings towards others. Here comes the role of socio cultural theory. Which refers the physical symptoms, being more acceptable, a way through which emotionally distressed individual communicates his/ her feelings or troubled thoughts.

Factors contributing to conversion disorder

The conversion disorder is attributed to recent psychological stressors or conflicts. Any type of physical, mental or emotional abuse can directly lead to conversion disorder. Like psychological abuse in work place, long delayed after effect of childhood abuse, parental neglect in childhood and sexual abuse.. In a study conducted, 46% people reported childhood trauma and 33% reported physical and sexual abuse which was the underlying cause of people suffering from conversion disorder. However, there are certain other factors which contribute to the development of conversion disorder. Conversion disorder affects people from the age of 10-35. Sex is also one factor. As discussed earlier, conversion disorder primarily found in women which indicated status of women especially in developing countries. Socio economic status also plays its part. People belonging to low socioeconomic groups, residing in rural areas with less education are more likely to suffer from this order [12].

Comorbidity is also an important factor here. Studies have shown that people suffering from conversion disorder have underlying psychiatric illness like depression, generalized anxiety and mixed anxiety depression. Another explanation to this factor may be, in my opinion, that depression or other underlying psychiatric disease opens the patients to sensitivity and stress thus making them more vulnerable to conversion disorder. Symptoms also depend on cultural variation. The stressors are different for different cultures, even primary symptom of conversion disorder also varies, and in Nepal, India and Pakistan people feel heat inside of their bodies when suffering from conversion disorder whereas Turkish experiences loss of consciousness. The symptoms are also acknowledged in some religious rituals of some cultures thus culture also influences the conversion disorder [13].

What needs to be done?

When dealing with patients who lack physical explanation of their symptoms, ruling out medical cause before the psychiatric referral is crucial to make diagnosis of conversion disorder. It often provokes frustration in therapist when patient doesn’t actually behave like one but, the doctor patient relationship is really important for the outcomes, therefore therapeutic relationship should be established in order to help patient recover as soon as possible. The principle treatment strategy for conversion disorder is to recognize and attend the traumatic or distressing life event of the patient. The therapist must ensure that patient is not receiving any benefits from the conversion symptoms [14].

Considering the possibilities of conversion disorder when a patient’s neurologic signs are atypical, make sure to decrease doing diagnostics again and again. These lots of investigations and tests may prolong symptoms. Early referral to neurology / psychiatry is another significant step to be taken. Monitor for other psychiatric morbidities especially depression and that needs to be treated if identified [15]. Medications are another important thing that plays great role in conversion disorder. These may include antidepressants and anxiolytics, primarily. Other medicines need to be decided on basis on symptoms [16].

CONCLUSION

In conclusion, conversion disorder is a functional neurologic disorder that cannot be explained by any medical condition. Its occurrence, symptoms and prevalence depends on many factors among which psychological stressor are regarded as the most important. Progression in clinical neuro-imaging techniques has started revealing secrets that were previously unidentified. There is a huge need of performing various clinical trials to bring more updated literature on the disorder.

REFERENCES

1. Sar V, Akyuz G, Kundakcı T, Kiziltan E, et al. (2004). Childhood Trauma, Dissociation, and Psychiatric Comorbidity in Patients with Conversion Disorder. Am J Psychiatry. 161(12): 2271-2276.

2. Feinstein A. (2011). Conversion disorder: advances in our understanding. CMAJ. 83(8): 915-920. 

3. Sastra S. (2013). A Disfluency Analysis of Psychogenic Stuttering Experienced By a Patient of Conversion Disorder in a Dangerous Method Movie. (YOGYAKARTA STATE UNIVERSITY).

4. Stone J, LaFrance WC, Levenson JL and Sharpe M. (2010). Issues for DSM-5: conversion disorder. Am J Psychiatry. 167(6): 626-627.

5. (2006). American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. 152(8): 1228.

6. Farooq S. (2007). Conversion disorder-A dilemma facing the psychiatrist in developing countries. JPPS. 4(1): 60-62.

7. https://www.theravive.com/therapedia/conversiondisorder2017 

8. Siddique I, Dogar IA, Haider NI and Afzal S. (2015). Prevalence Of Anxiety And Depression In Patients With Dissociative Disorders. JPPS. 12(1): 21-23.

9. Ali S, Jabeen S, Pate RJ, Shahid M, et al. (2015). Conversion disorder—mind versus body: a review. Innovations in clinical neuroscience. 12(5-6): 27-33.

10. Levenson JL and Sharpe M. (2016). The classification of conversion disorder (functional neurologic symptom disorder) in ICD and DSM. Handb Clin Neurol. 139: 189-192.

11. http://www.jpma.org.pk/full_article_text.php?article_ id=2608

12. Barlow D and Durand V. (2012). Abnormal Psychology-An integrated Appr. 6th ed., pp. 180-190). Wadsworth cengage learning.

13.  Nuckols C. (2013). Diagnostic and statistical manual of mental disorders (5th ed.65-66). American psychiatric association.

14. Owens C and Dein S. (2006). Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment. 12(2): 152-157.

15. http://ajp.psychiatryonline.org/doi/full/10.1176/ ajp.2006.163.9.1510

16. Roelofs K, Keijsers G, Hoogduin K, Naring G, et al. (2002). Childhood Abuse in Patients with Conversion Disorder. American Journal of Psychiatry. 159(11): 1908-1913.