CONVERSION OR DISSOCIATIVE DISORDERS: The terms
conversion and dissociative disorders are used to describe mental
processes by which unconscious emotional conflicts are resolved through
physical or mental symptoms without related pathology.
They replace the term hysteria (the wondering womb).
Charcot, the French neurologist, stated that hysteria is the result of a
functional (disturbance of function as opposed to organic) disorder of the
brain, which causes physical symptoms.
The patient also becomes easily suggestible and under hypnosis further
symptoms can be elicited.
Pierre Janet, another French neurologist and a pupil of Charcot,
suggested that in hysteria, the integration between different parts of
mental functioning is lost (dissociation). Dissociation of mental
functioning restricts awareness and allows emotional conflicts to be
expressed as mental or physical symptoms.
Freud and Breuer, two Austrian neurologists suggested that sexual
conflicts repressed in the unconscious are the cause of hysterical
symptoms. The emotional conflict causes anxiety if it reaches
consciousness and is converted to physical symptoms to avoid anxiety.
The symptoms represent a symbolic solution to the conflict and the
patient shows little concern about it (primary gain).
Kretchmer, the German neurologist suggested that hysterical symptoms
are the result of failure of an innate biological mechanism that normally
counteracts stressful experience. He also suggested that persistence of the
symptoms is related to secondary gain (benefiting from the
symptom=sick role) and becoming a habit.
In ICD-10, the mental and physical manifestations of hysteria are
classified as dissociative disorders.
In DSM1V, physical symptoms are called conversion disorders and
classified as somatoform disorders and dissociative symptoms as
dissociative disorders.
Symptoms of conversion disorders are related to the motor or sensory
function of the voluntary division of the nervous system. Symptoms can
be positive (tremor, convulsions, paraesthesia, pain) or negative (sensory
deficit, paralysis, blindness).
The pattern of presentation of the symptoms is influence by the patient’s
medical knowledge, previous personal experience of physical illnesses,
and exposure to physical illnesses of others.
The general features of conversion symptoms include:
1- difficulty to interpret on anatomical and physiological grounds.
2- variability in extent and severity.
3- worsen when the patient feels being observed or asked to
demonstrate them.
4- cause little concern and inconvenience to the patient( la belle
indifference)
5- are not accompanied by related neurological signs (muscle
wasting, change in tendon reflexes, Babinski’s sign).
6- The more medically naive the patient,the greater the likelihood of
implausible symptoms.
Conversion seizures are not accompanied by alteration of
consciousness; movements are jerks in all directions and irregular;
there is no urinary or faecal incontinence; may occur by suggestion;
pupillary reflexes are normal; and the EEG is normal immediately or
during the seizures. Visual and brain stem evoke responses are normal
in conversion blindness and deafness.
The diagnosis of conversion disorders should not be made only on
normal clinical examination (by exclusion), but should be supported
by history and comprehensive psychiatric assessment.
The presence of psychological conflict or stress that preceded the
initiation or exacerbation of the symptoms is essential for the
diagnosis of conversion disorder.
After the diagnosis becomes clear, repeated physical examination and
investigations may reinforce the patient’s conviction of a physical
illness.
Uncertainty of the treating doctor has a negative influence on the
success of treatment, and physical treatment should be kept to a
minimum.
Epidemiology: It is the most common somatoform disorder.It is more
common
amongfemales,rural
population,those
with
low
socioeconomic status and in developing regions.Rare n those younger
than 10 years and those older than 35 years
Etiology:
1-Dynamic hypothesis:the conversion symptom is resolution of
unconscious conflict.
2-Altered function of both hemispheres and impaired cortical
communication,PET studies.
3-Hypercritical families may create unspeakable dilemmas.
DD
Diseases characterised by relapse and remission of multiple symptoms
(MS, SLE, AIDS), and fluctuating severity of symptoms (myasthenia
gravis, myalgic encephalomyelitis, SLE, MS) can be mistaken for
conversion disorders.
Neurological diseases are diagnosed in one-fifth to one-half of patients
with conversion disorder.
Prognosis:
Good prognosis is associated with acute onset,clear stressor,short interval
between onst of symptom and initiation of treatment,above-average
intelligence and presenting symptoms of paralysis,aphonia,or blindness.
Poor prognosis is associated with presenting symptoms of tremor and/ or
seizure , lowIQ.
Treatment
Support, reassurance, and interpretation of the symptoms on
psychological bases are helpful (indirect examination of stressors can
lead to relief).Avoid confrontation ,as it result in loss of
face.Treatment of any associated psychiatric disorder