Conversion Disorder: An Analysis of the Hysterical

Historically termed “hysteria” and thought to be a physical manifestation of disordered emotions, little is known about the mystery that is conversion disorder (5). In the seventeenth century, some individuals with unexplained paralysis, blindness or “fits” (seizures) were thought to have been involved with witchcraft and were burned at the stake (2). Nowadays, these symptoms are considered relatively common and oftentimes debilitating. Although not much is known about conversion disorder, it seems possible that the neurological processes responsible for its development are related to those involved in anxiety and depression disorders. It also seems that, while not a prerequisite, past trauma or abuse highly elevates one’s probability for developing this common, but obscure disorder.

Conversion disorder is a somatoform disorder (mental disorders with physical symptoms that mimic disease) characterized by medically unknown and often disabling neurological symptoms. Our knowledge of this disorder and how psychological stressors are “converted” into physical symptoms is very limited and it has been very difficult to gather information about this disorder. However, psychological factors have been determined to be involved, as stressors generally precede the onset of symptoms (3).  Individuals diagnosed with conversion disorder present with at least one unfeigned and unintentional symptom, which affects voluntary motor or sensory function, resembles a neurological or medical disease, and involves psychological elements (5). Such symptoms may include impaired coordination, paralysis, weakness, difficulty swallowing, double vision, blindness, deafness, seizures, amnesia and loss of consciousness (6).

Evidence has been found which suggests that certain portions of the brain might be related to the disorder, but, again, as limited research has been done in this field and little is known about the disorder itself, it is difficult to validate these results. This evidence, summarized and presented in an article by Harvey et. al, suggests that frontal cortical and limbic activation related to emotional stressors may inhibit basal ganglia and thalamus function, causing an inability in patients to consciously process sensory and motor inputs (4). In addition, blindsight, a condition in which individuals are perceptually blind in part of their visual field, involves a decreased consciousness of visual stimuli. Neural studies of blindsight and hysterical blindness found in conversion patients have shown their foundations to be very similar and this may be useful in determining other regions in the brain that may be involved in conversion symptoms (3). Conversion disorder is closely related to the conscious and unconscious mind, as it seems that conscious perception of stimuli is inhibited and unconscious behavior promoted in affected individuals. What this all means is that somehow the connections between the portions of the brain that process information as well as the portions of the brain that are responsible for a person’s willed actions have been altered and are different from those in unaffected individuals. The question is what exactly causes these alterations?

As previously stated, conversion disorder is classified as a somatoform disorder, along with somatization disorder, hypochondriasis, body dysmorphic disorder, and pain disorder. A recent study done in the Netherlands has shown a correlation between somatoform disorders, depression, and anxiety.  54% of patients studied with an anxiety or depressive disorder were shown to also have a somatoform disorder and, of all the 116 patients determined to have a somatoform disorder, 26 appeared to also have an anxiety or depressive disorder (1). These results seem too high for comorbidity, or coexistence, of the three disorders to be unrelated. While conversion disorders can occur without anxiety or depression symptoms and vice versa, the high percentage of individuals with anxiety or depression that also had somatoform disorders suggests the possibility that the portions of the brain (and the connections) that are responsible for anxiety and depression could also be involved in the development of conversion symptoms.

Another factor that could be a possible cause of conversion disorder is that of abuse, specifically during one’s childhood. In 1991, Marybeth Hendricks-Matthews wrote an article about the case of a 22-year-old woman who presented with continuous belching episodes lasting over 24 hours over the past 2-½ years. The woman was unintentionally swallowing air for unknown reasons and while seeing a psychologist about the problem, she admitted that her father had sexually abused her as a child. The patient’s father had been abusive to her mother, they had divorced when she was 7-years-old, and she would develop asthmatic attacks and “blackout spells” whenever she visited him (4). These early symptoms of conversion disorder could be defense mechanisms that she unconsciously produced in order to remove herself from the situation either mentally or physically. This past trauma seems to be especially relevant to her development of conversion disorder and the development of symptoms seem to be related to an unconscious need to protect her mind from her past memories. In addition, the development of the new belching symptoms (just after she began dating, no less) seems to be both a physical plea for help and a manner of unconsciously forcing herself to face her psychological problems.

Additional research has been conducted to determine the correlation between childhood abuse and conversion disorder. In a study done by Roelofs et. al, patients with conversion disorder (some of whom also showed evidence of mood disorders, panic disorders, PTSD, etc.) were cross-examined with patients with one or more affective disorders (major depression, panic disorders, social phobias, etc.). It was determined that conversion disorder is directly related to a higher frequency and more severe forms of physical and sexual abuse than the affective disorders. Physical abuse and maternal dysfunction seemed to be related to a higher severity of pseudoneurological symptoms in conversion disorder in comparison to sexual abuse and paternal dysfunction. These results are intriguing because of the extreme discrepancy in symptoms in maternal versus paternal abuse and it will certainly be important to determine the psychological reasoning behind the higher intensity of symptoms due to maternal dysfunction. What causes the portions of the brain (and their connections) responsible for conversion disorder to produce such dramatically different responses to these traumas? Finally, it was determined that an individual’s capability for autohypnosis (their ability to dissociate from reality) is potentially related to their capacity for dissociative conversion symptoms (6). This is highly interesting because further research on the neurological processes involved in hypnosis could provide insight to the mechanisms involved in this disorder.

Despite the research done on conversion disorder, none of the evidence can be considered definitive. While the study done in the Netherlands seems to show a correlation between conversion disorder and anxiety and depression disorders, the sample size was small and further studies are needed to corroborate their assertions. Hendricks-Matthew’s case study is sound and interesting but it is just that, a single case study, and other case studies need to be taken into consideration in order to form a judgment about the overall psychology and neurology behind the disease. Furthermore, the study done by Roelofs et. al was a retrospective study in which memory bias could have played a part and trauma reported by patients could not be verified by police reports or relatives due to the confidentiality of the study. Despite this, the findings do seem to explain the evidence collected on conversion disorder thus far. Hopefully further research will be able to determine a neurological mechanism for the disorder that explains the disorder’s apparent connection to anxiety and depression as well as to past childhood trauma. It will also be interesting to determine how the disorder develops in individuals with no other psychopathic symptoms or history of trauma.

Due to the variation in patient symptoms and responses in this relatively unexplained disorder, effective treatment differs for each patient. Some patient’s symptoms are suddenly resolved upon an explanation of the disease. In many cases, cognitive-behavioral therapy (7), which is also effectively used to treat anxiety and depression, is used in combination with physiotherapy and pharmacotherapy (for other underlying psychiatric disorders) (1,5). Family therapy can be helpful as an individual’s family is generally involved in helping them out with their neurological symptoms (5). In addition, as individuals diagnosed with conversion disorder are thought to be more susceptible to hypnosis, this has been used as an attempt to either reduce symptoms or force the patient to remember a past trauma. Sometimes treatments can be effective. For example, in the case of the girl mentioned in Hendricks-Matthew’s article, her particular belching symptoms decreased as the sessions with a psychologist addressing her past abuse increased. Unfortunately, however, she had begun showing signs of clinical depression as well (4). Future investigation of the disorder will breed further treatment options and we can only move forward from this point.

Thus, conversion disorder appears to be related to anxiety and depression disorders as well as to past traumatic events. However, while studies of conversion disorder have produced some interesting and potentially in-the-right-direction results, they have left us with many more questions about the disorder than we started off with. How can the unconscious overpower conscious free will and is this related to an individual’s aptitude for autohypnosis? Is the neurological mechanism for the production of conversion disorder symptoms connected to the mechanism involved in anxiety and depression? Does conversion disorder influence one’s potential for an anxiety or depression disorder or is it the other way around? Why does physical abuse and maternal dysfunction cause a higher incidence and greater severity of conversion symptoms than sexual abuse and paternal dysfunction? And finally, how can we treat individuals with this disorder when we don’t fully understand it?

References

1. Arehart-Treichel, Joan. "Comorbidities Often Accompany Somatoform Disorders." Psychiatric News 02 JUL 2004: 52. Web. 21 Feb 2010. <http://pn.psychiatryonline.org/content/39/13/52.1.full>.

2. "Conversion Disorder." Human Diseases and Conditions. 2010. Advameg, Inc., Web. 22 Feb 2010. <http://www.humanillnesses.com/Behavioral-Health-Br-Fe/Conversion-Disorder.html>.

3. Harvey, Samuel B, Biba R Stanton, and Anthony S David. "Conversion disorder: towards a neurobiological understanding." Neuropsychiatric Disease and Treatment. 2.1 (2006): 13-20. Print.

4. Hendricks-Matthews, Marybeth. "Conversion disorder in an adult incest survivor." Journal of Family Practice Sep 1991. Web. 22 Feb 2010.

5. Owens, Colm, and Simon Dein. "Conversion disorder: the modern hysteria." Advances in Psychiatric Treatment. 12. (2006): 152-157. Print.

6. Roelofs, Karin, Ger P.J. Keijsers, Kees A.L. Hoogduin, and Franny C. Moene. "Childhood Abuse in Patients With Conversion Disorder." American Journal of Psychiatry. 159.11 (2002): 1908-1913. Print.

7. Warman, Debbie M. "Cognitive-Behavioral Therapy." National Alliance of Mental Illness. Jun 2003. NAMI, Web. 22 Feb 2010. <http://www.nami.org/Template.cfm?Section=About_Treatments_and_Supports&template=/ContentManagement/ContentDisplay.cfm&ContentID=7952>.