Freud proposed a different mechanism in which unwelcome experiences are
‘repressed’ into the unconscious but in doing so become converted into physical
symptoms: ‘she repressed her erotic idea and transformed the amount of its
affect into physical sensations of pain.’ Freud argued that although
the repression was deliberate, in order to escape from distress (which he called
primary gain), the conversion was not: ‘The splitting of the consciousness... is
accordingly a deliberate and intentional one....the actual outcome is something
different from what the subject intended.’ “Secondary gains” could also accrue
as the resulting physical symptoms enabled escape from conflicts or other
unwanted outcomes- for example, paralysis stopping a partner leaving or
resulting in more attention from a significant other. Freud later revised his
view to argue that these traumas were only so debilitating because they awakened
memories of childhood sexual abuse and then dropped the latter idea in favour of
his theory of infantile sexuality. Although he subsequently revised this view
again, those early ideas of repression, conversion and sexual abuse come to
dominate post-Freudian psychiatric models of hysteria.9,10
The acceptance of these models changed hysteria from a neurological
condition akin to migraine into a purely psychiatric disorder. Over the 20th
century, psychiatrists embraced the condition even as they noted its apparent
disappearance from their clinics.11 Hysteria entered the diagnostic
classification, with terminology that embodied the dominant Freudian model-
conversion hysteria in the latter part of the century. As enthusiasm for
biological psychiatry grew, in the UK in particular, there were moves to a more
neutral model12 and the term dissociation, still in common use in
psychological circles, re-entered the nomenclature in ICD-10, describing
‘dissociative seizures’ and becoming a synonym in ‘dissociative (conversion)
Episodes of conversion disorder are nearly always triggered by a
stressful event, an emotional conflict or another mental health disorder, such
as depression. The exact cause of conversion disorder is unknown, but the part
of the brain that controls muscles and senses may be involved. It may be the
brain’s way of coping with something that seems like a threat.
The old term for conversion disorder was hysteria. Physicians in ancient
Greece believed that hysteria occurred in females and that it was caused by the
uterus wandering in the body (the greek word for uterus is hysteria). For
centuries thereafter, people with hysteria were regarded as fakers or imagining
their symptoms. In the 17th century, some people with hysteria were
thought to be involved with witchcraft and were burnt at the stake.
The term conversion disorder came into use only in the 20th
century. It is derived from the early work of the Australian physician Sigmund
Freud, the founder of psychoanalysis.
Freud believed that in times of extreme emotional stress, painful
feelings or conflicts are repressed (kept from awareness or consciousness) and
are converted into physical symptoms to relieve anxiety. Even in the 21st
century, mental health experts do not all agree on the precise psychological
mechanisms underlying conversion disorder. However, many mental health
professionals see the benefits associated with the symptoms of conversion
disorder, such as sympathy, care and the avoidance of stressful situations, as
significant to the disorder.
Conversion symptoms are more common among the uneducated and
unsophisticated, the actual conversion symptom itself is generally a reflection
or extension of symptoms that the patient has seen in another or has personally
In most instances, consequent upon the appearance of the conversion
symptom, there is a reduction in the patient’s level of anxiety. Close
inspection reveals that conversion symptoms are not, however, premeditated; they
simply happen – and although observers may feel a “purpose” is behind them, the
patient himself is unaware of any such thing. Many clinicians feel that the
symptoms itself may be a kind of sign language or a sort of hieroglyphic that
conveys what the patient is unable to put into words.
Recent PET scanning has demonstrated that in patients with conversion
hemiplegia or hemianaesthesia, there is a decreased activation of the
contralateral basal ganglia and thalamus.13 The pathophysiologic
relevance of this finding, however is unclear. It may represent a premorbid
susceptibility to the development of conversion symptoms or might, in turn,
merely be epiphenomenal and unrelated to the underlying cause or causes.
Controversy about the cause
Around 25% of conversion disorder patients are later diagnosed with
authentic medical ailments that account for their symptoms. The complexity of
conversion disorder is magnified by the fact that genuine illness and conversion
disorder can co-exist. Sometimes, for instance, patients with genuine epilepsy
have conversion seizures as well. In a true grand mal seizure, a patient has
massive electrical discharges from all parts of his or her brain, leading the
body jerking and tongue biting. In conversion disorder on the other hand, the
patients have normal brain activity even when they appear to be in throes of a
Conversion disorder can present with any motor or sensory symptom
including any of the following:
Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor
Impaired vision (hysterical blindness) or impaired hearing.
Loss/disturbance of sensation
Impairment or loss of speech (hysterical aphonia)
Psychogenic non-epileptic seizures
Fixed dystonia unlike normal dystonia
Tremor, myoclonus or other movement disorders
Gait disturbances (astasia-abasia)
10. Hallucinations of a
childish or fantastic nature
11. Tourette-like symptoms
Mass Psychogenic Illness
DSM-IV TR does not have a specific diagnosis for mass psychogenic illness
but the text describing conversion disorder states that in ‘epidemic hysteria’,
shared symptoms develop in a circumscribed group of people following exposure to
a common precipitant.
Conversion disorder may pursue either an episodic or chronic course, with
the initial conversion symptom remitting spontaneously, often within weeks or
months. In such cases, a subsequent episode may be expected in the years to
come. Should such a subsequent episode occur, the conversion symptom itself may
be different from the initial one.A minority of patients experience their
conversion symptoms chronically; this tends to be the case with an associated
Should patients take to bed or restrict their activities because of
conversion symptoms, jobs may be lost and relationships strained. Potentially
dangerous diagnostic procedures, such as arteriography may be undergone. In
chronic cases of conversion paralysis, disuse atrophy or contractures may occur.14
After the diagnosis is made, one should inform the patient in a gentle
and nonjudgmental, yet quietly authoritative way that neither the examination
nor the diagnostic tests have revealed any damage to the brain or nerves. One
may then confess honestly that, although medicine does not know the cause of the
symptoms, it is nevertheless known that patients tend to recover in a few weeks.
With such support and reassurance, a majority of patients will experience a
remission during a hospital stay and this is especially likely when the
conversion symptoms have been of acute onset and short duration and were
preceded by an obvious psychosocial precipitant. In certain instances, a few
sessions with a physical therapist that is knowledgeable about these patients
may expedite the remission, often providing a sort of “face-saving” device. At
all costs, one must avoid pejorative statements such as “there is nothing really
wrong with you” as these only serve to undermine the physician-patient
When these measures fail, alternative techniques may be used. Hypnosis
may effect a remission; however early relapses tend to occur.15
Another approach involves viewing the symptoms as a kind of “sign language”,
deciphering what the sign means and then assisting the patient in putting that
meaning into words and taking appropriate action.16 Such an approach
is often labour intensive, yet the clinical impression is that it may produce
Working with the family unit may be necessary when family and
sociocultural factors predominate, particularly in children and adolescents.
Family therapy interventions help the patient and family recognize and address
key issues which may be fuelling the symptoms. For example, in an analysis of
videotaped family interviews of adolescent patients, an unspeakable dilemma was
imposed by family or social circumstances in 13 of 14 cases, leading patients
with nonepileptic seizures to suppress emotional distress.17
Recognition and treatment of comorbid psychiatric conditions are almost
always necessary for symptom resolution. If patients continue to be symptomatic
after these risk factors have been addressed, then psychological treatments that
focus more directly on perpetuating factors will be necessary. Patients’
reactions (and physicians) reactions to their conversion symptoms can serve to
unwittingly perpetuate them. Avoidant behaviours, minimisation of psychological
factors and suppression of expression of distress reinforce an external locus of
control. Cognitive behaviour therapy lends itself well to addressing these
issues. It is specifically helpful in addressing illness beliefs and denial of
stress and in modifying the locus of control.18
Psychodynamic psychotherapy can also serve to help patients reframe their
world view through empathic interpretations and the development of insight,
enabling the process of working through past trauma rather than on relying on
dissociation as a defense. Both approaches will increase awareness of
Early recognition of a conversion disorder will limit unnecessary tests
and medications. Long term benefit requires a comprehensive treatment approach,
recognition of risk factors and treatment of comorbid conditions, with a focus
on cognitive styles that perpetuate symptoms. The quality of the doctor-patient
relationship can influence the outcome. Hard-to-treat patients may engender
feelings of powerlessness, frustration and mistrust in their treaters, which if
unprocessed may lead to a poor relationship and excessive use of medications,
tests and procedures. There are few published reports on prospective studies or
controlled trials of treatment for patients with nonepileptic seizures. The
existing medical literature supports a multidisciplinary treatment approach,
with specific interventions, such as cognitive behaviour therapy for cognitive
restructuring and psychodynamic therapy for addressing symptom connections to
trauma and dissociation. Adjunctive group therapy or family therapy works well
for certain patients. Hypnosis can be beneficial, although it is not essential
for a good outcome. Judicious medication treatment for comorbid disorders, alone
or in combination is often needed for sustained therapy.
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