CONVERSION DISORDER

Conversion disorder is defined by one or more physical symptoms that are not under
voluntary control and are not thought to be caused by neurological or medical conditions. The
key feature of this disorder is thus the incongruence between presented symptomology and
medical conceptualizations of organic diseases. The most commonly observed conversion
symptoms include blindness, psychogenic non-epileptic seizures, paralyses,
unresponsiveness, anesthesia, aphonia, and abnormal gait.

Theories of Etiology
Psychoanalytic theory
Psychoanalytic formulations of conversion disorder suggest that the medically
unexplained physical symptoms represent expression of forbidden urges, unconscious
drives, as well as the need to suffer or identify with a loss. A history of childhood
sexual and physical abuse has also been associated with conversion disorder,
suggesting that childhood traumatization may pose as a risk factor in some
individuals. While it remains unclear how stresses, traumas, or psychologically
threatening or socially unacceptable thoughts translate into somatic symptoms,
conversion symptoms are viewed as a consequence of a defense mechanism that
occurs outside of the patient’s awareness. Freud's principle of conversion and
repression model of hysteria suggested that psychological conflicts, too difficult to
process consciously, were "converted" or transformed into physical symptoms.
Kardiner and Spiegel (1947) described the traumatic etiology of conversion symptoms
and posttraumatic disorders associated with combat experience. They conceptualized
such conversion symptoms as a nonverbal language of action or the expression of
conflict over fear and loyalty to comrades resulting in apparent physical dysfunction
that provided an honorable exit from an intolerable situation (Spiegel 1974). They
also demonstrated the usefulness of hypnosis in diagnosing and treating both
conditions.

Sociocultural theories
Sociocultural formulations place an emphasis on gender roles, religious beliefs, and
other sociocultural influences that may prohibit or dictate culturally acceptable ways
to express emotion. Today conversion disorders are more commonly diagnosed in
women, tend to affect individuals from lower socioeconomic status, rural
communities, and individuals with limited knowledge of physiology and anatomy.
Differences in prevalence rates of conversion disorders across cultural groups are
unclear due to inconsistent methods of assessment. However, some findings have
shown that psychogenic non-epileptic seizures and loss of consciousness as more
common in some contexts (e.g., Turkey, Oman, and India), while other settings have
more frequently reported motor disturbances (Netherlands) or visual disturbances
(Japan). Certain cultural syndromes, such as ataques de nervios (e.g., in Puerto Rico)
may include similar medically unexplained symptoms such as loss of consciousness,
faintness, convulsions, and blindness.
Barr and Abernethy (1977) posited a behavioral approach to understanding
conversion symptoms, suggesting that "conversion is an adaptation to a frustrating life
experience."

Learning theory and secondary gains

The social learning perspective emphasizes the role of the environment and
reinforcement in behavior. Of particular importance in this model is the concept of
secondary gains— the benefits of the sick role behavior. Secondary gains, whether
financial or interpersonal, act as a reinforcing consequence of the presenting
symptoms and maintain the conversion disorder. Positive reinforcement of the sick
role behavior or the effect of secondary gains on symptoms maintenance may happen
without the patient’s conscious awareness.
Regardless of the underlying pathogenic mechanism, the diagnosis of conversion
disorder may be complicated by some patients' tendency to model their symptoms
after their own physical illnesses. Watson and Buranert (1979) called this “a
paralogical extension of physical disease." That is, patients may mimic symptoms
they experienced in the past (paralogical extension) or may unconsciously replay the
symptoms experienced by a significant person (object) (symptom identification)
(Lazare 1978; Lewis and Berman 1965). Or, as postulated in the "learned behavior"
theory, symptoms learned during childhood are later used in adult life to cope with
particular situations (Barr and Abernethy 1977).
Celani (1976) described conversion symptoms as '-the result of cultural, social, and
interpersonal influences," and the way the patient has "learned to communicate
helplessness, thereby facilitating an environment in which attention and support are
 gained and aggressive impulses avoided." Celani suggested that secondary gains are
common in conversion disorder by stating that "the patient's symptoms may be
reinforced by the reactions of caretakers and families [secondary gains) perpetuating
symptoms and symptom formation during times of stress and conflict."

Neurobiological correlates of conversion

The search for neural mechanisms by which psychological stressors translate into
somatic symptoms is complicated by the low base rates, heterogeneity of symptoms,
frequent comorbidities with anxiety and depression, as well as secondary gains and
other psychological determinants of the behavior. Despite the paucity and the
heterogeneity of data, preliminary findings across studies point to converging
mechanisms. Several investigations using functional magnetic resonance imaging and
single-photon E. Yakobov et al. 279 emission-computed tomography found
associations between sensory and motor conversion symptoms and altered activity in
the basal ganglia, as well as brain areas that are implicated in regulating and
expressing emotion. The results of these studies suggest that an abnormal pattern of
activation in these regions may inhibit the activation of motor and sensory cortices,
thus suggesting a mechanism by which intense emotion may override brain regions
associated with sensory or motor function. Future research is needed to further
replicate these findings and determine their relevance for clinical practice.

CASE REPORT
A 10 year old boy, Standard V student, presented complaints of stiffness in body and
inability to flex knee joints.
History revealed occasional complaints of body pain for the last 2 months which was
relieved by body massage. One week back the boy complained of body pain and vomited
after having breakfast. He was not sent to school. He slept for about 2 hours and woke with
stiffness of body and inability to flex upper and lower limbs. He was admitted in a hospital,
where he regained mobility of the upper limbs but was not able to bend his knees and walked
with a stiff gait. His mother noticed that when the child was asleep his limbs were not rigid
and would be flexed. The following morning he was able to walk and run. When discharge
was planned there was a relapse. He was then referred to the Department of Clinical
Psychology, SRU.
 There was no significant past history of psychiatric or neurological disturbances.
Developmental history was reported to be unremarkable. Family relationships were reported
to be cordial. Problems in the school were reported. A gradual decline in performance was
reported. He felt discriminated against and victimised by his class teacher and expressed
strong resentment for not getting required attention and reinforcement from his class teacher.
Psychological evaluation using Children’s Apperception Test (CAT) and Malhotra’s
Temperament Scale (MTS) did. However, good prognostic indicators were elicited in terms
of resolution of problems and favourable outcomes. The clinical picture is indicative of a
diagnosis of Conversion Disorder.
The child was seen for five therapy sessions. On the first visit the child was seen to be
sitting in the chair with his legs held parallel to the ground since he was not able to flex his
knees. He was dragging his feet while walking. The child was provided reassurance regarding
the management of symptoms. Possible consequences of persistence of symptoms were also
discussed. He was made to do movement exercises by slightly moving his feet preceded by
deep breathing. As he was moving his feet suggestions of increased flexibility were given.
With continued effort of 10 – 15 minutes he could bend his knees and sit in a normal position
for a brief period. His effort to move his lower limbs were encouraged and appreciated. The
child was asked to continue the movement exercises at home and given a suggestion that he
would flex his knees at right angles. In the second session held the next day the child walked
less stiffly and was able to bend his knees to right angles as suggested. His parents were
educated about the psychosomatic nature of his symptoms and advised to encourage him for
developing a symptom free lifestyle. They were also told not to pay attention to his
complaints of physical symptoms.
By the third session held the next day, his gait was normal. He reported to have pain
in his lower limbs but was able to flex his knees. He was still unable to bend his knees fully.
He was reinforced for the improvement and asked to continue the movement exercises at
home and resume all usual activities.
Addressing the school related issues he was allowed to talk about alternatives
available to deal with the current situation. His parents were advised to allow him to
communicate his difficulties freely, look at issues objectively and help him develop an
adaptive coping style.
The child was asymptomatic and had resumed his earlier routine by the fourth session
which was held the next day. He was seen once more after a period of one week during which
improvement was maintained. Follow up was maintained for 2 more sessions with the parents
with a week’s interval in between during which also improvement was maintained.
Telephonic contact was maintained upto 3 months during which he continued to be symptom
free.

Udisha Merwal (375)

Year III