Conversion Disorder — Mind versus Body: A Review, 2015, Ali et al

[livinglighter]

Abstract
In this article, the authors accentuate the signs and symptoms of conversion disorder and the significance of clinical judgment and expertise in order to reach the right diagnosis. The authors review the literature and provide information on the etiology, prevalence, diagnostic criteria, and the treatment methods currently employed in the management of conversion disorder. Of note, the advancements of neuropsychology and brain imaging have led to emergence of a relatively sophisticated picture of the neuroscientific psychopathology of complex mental illnesses, including conversion disorder. The available evidence suggests new methods with which to test hypotheses about the neural circuits underlying conversion symptoms. In context of this, the authors also explore the neurobiological understanding of conversion disorder.

Keywords: Conversion disorder, hysteria, unconscious conflict, repressed idea, psychoanalytic factors, psychogenic nonepileptic seizures, conversion anesthesia, therapeutic alliance, striatothalamocortical circuits

INTRODUCTION
Conversion disorder, also called functional neurological symptom disorder,1 is defined as a psychiatric illness in which symptoms and signs affecting voluntary motor or sensory function cannot be explained by a neurological or general medical condition.2 Psychological factors, such as conflicts or stress, are judged to be associated with the deficits.3 The term conversion disorder was coined by Sigmund Freud, who hypothesized that the occurrence of certain symptoms not explained by organic diseases reflect unconscious conflict.3 The word conversion refers to the substitution of a somatic symptom for a repressed idea.3,4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479361/

 

[livinglighter]

Common examples of conversion symptoms include blindness, paralysis, dystonia, psychogenic nonepileptic seizures (PNES), anesthesia, swallowing difficulties, motor tics, difficulty walking, hallucinations, anesthesia, and dementia.5 In patients with conversion disorder, these symptoms are not caused directly by a physiological effect; rather these symptoms are caused by a psychological conflict. Patients diagnosed with conversion disorder are not feigning the signs and symptoms. Despite the lack of a definitive organic diagnosis, the patient’s distress is very real and the physical symptoms the patient is experiencing cannot be controlled at will (i.e., the patient is not malingering an illness). As an example, according to the Medline Medical Dictionary,6 “...a woman who believes it is not acceptable to have violent feelings may suddenly feel numbness in her arms after becoming so angry that she wanted to hit someone. Instead of allowing herself to have violent thoughts about hitting someone, she experiences the physical symptom of numbness in her arms.”

ETIOLOGY
Conversion disorder is associated with conflicts or recent stressors, and its symptoms manifest as a result of unconscious conflict between a forbidden wish of the patient and his or her conscience. The conversion symptoms symbolically represent a partial wish fulfillment without the individual’s full awareness of the unacceptable desire3 (e.g., vaginismus with sexual desire, syncope with arousal, paralysis with anger). Conversion disorder has been attributed to both nonbiological and biological factors (Figure 1).3,14

 

[Arnie Pye]

Patients diagnosed with conversion disorder are not feigning the signs and symptoms.

But doctors think patients are feigning and therefore don't really look into the patient's symptoms with any seriousness, and certainly not with any view of doing a complete diagnostic job. And nothing about conversion disorder, FND, and MUS leaves any room for dealing with doctors who are mistaken in their diagnosis and in fixing things for patients who are physically ill with a medical problem that can be fixed, but they've been wrongly diagnosed.

This is my biggest beef with all these "diagnoses" i.e. conversion disorder, hysteria, FND, MUS, Somatic Symptom Disorder, Bodily Distress Disorder, and others of that ilk. They all seem to be the same condition from my point of view, and all patients so diagnosed are all treated the same. And if the doctor got it wrong there is no recognised way for the patient to back themselves out of the cul-de-sac doctors have pushed them into, and no way for the patient to get the doctor to reconsider. And what are the chances that any doctor who diagnosed one of these conditions will agree to send a patient for a second opinion with any doctor who wasn't in the mental health field?

 

[Hutan]

And if the doctor got it wrong there is no recognised way for the patient to back themselves out of the cul-de-sac doctors have pushed them into, and no way for the patient to get the doctor to reconsider.

Indeed. Even when the patient goes on to have florid symptoms of some physical disease that without question would have caused the initial symptoms, even when the patient dies of that physical disease, we have seen published case studies where the initial diagnosis of a 'functional disease', a conversion disorder, is still held to be correct. It is presented as a 'functional overlay', incredibly, even in a case of Creutzfeld-Jakob disease, as if some past emotional trauma is required to explain the symptoms resulting from a disintegrating brain.

We see no convincing evidence that any treatment based on this 'conversion' hypothesis works. But a little bit of empathy is all that is required to see the various harms that such a label can cause. The one great benefit seems to be for medical professionals, as the concept allows the avoidance of feelings of ignorance and inadequacy.

 

[EndME]

What is the etymology of the terminology "conversion disorder"? Is it related to the same medical professionals and/or disciples that used to be certain that for example "homosexuality" was a psychological disorder that could be effectively cured with "conversion therapy"?

 

[SNT Gatchaman]

No, see the quotes in post #2. But to summarise, the idea was that there was nothing actually wrong with the body - instead psychological distress/conflict is converted into bodily (somatic) symptoms.

Psychological factors, such as conflicts or stress, are judged to be associated with the deficits. The term conversion disorder was coined by Sigmund Freud, who hypothesized that the occurrence of certain symptoms not explained by organic diseases reflect unconscious conflict. The word conversion refers to the substitution of a somatic symptom for a repressed idea.

In patients with conversion disorder, these symptoms are not caused directly by a physiological effect; rather these symptoms are caused by a psychological conflict.

 

[Hutan]

In that diagram in post #2 - Etiology

Psychoanalytic factors - symptoms have symbolic relationship to the unconscious conflict (e.g., vaginismus protect the patient from expressing unacceptable sexual wishes).

Learning theory - symptoms of illness learned in childhood are called forth as a means of coping with an impossible situation.

Biological factors - symptoms are caused by impaired cerebral hemisperic (sic) communications and excessive cortisol arousal that inhibit the individual's awareness of bodily sensations. The patient may also exhibit subtle impairments on neuropsychological tests.

 

[livinglighter]

I found the whole paper eye-opening. I wasn't sure how much I could include on this site, but it is definitely worth a read.

 

[EndME]

No, see the quotes in post #2. But to summarise, the idea was that there was nothing actually wrong with the body - instead psychological distress/conflict is converted into bodily (somatic) symptoms.

Thanks, but I'm not sure if that does answer the question, I think I just know too little about the subject. For homosexuality being viewed as psychological disorder and then treated with "conversion therapy" very similar beliefs were present and there is a Freud connection as well as a connection to other psychoanalysts. But I know absolutely nothing on the detailed history of these terms and how they were connected or used back then.

In that diagram in post #2 - Etiology

Aren't these very similar or the same theories to justify "conversion therapy"?

 

[duncan]

There's a Woody Allen movie in there somewhere.

 

[SNT Gatchaman]

I think the conversion in Gay conversion therapy refers to the active aim on the part of the person "treating" to convert the patient "back" to cis-heterosexual norms. Ie the therapy is conversion away from gay, rather than therapy for a previous conversion to gay.

You're right that some of the wacko theories included the idea that repressed psychological conflict (eg in childhood) were the cause of teh gay. Admittedly I haven't read much on this, but haven't seen the term "conversion" used in that context, but you may well be right. Others likely have better knowledge of this. Needless to say, all ghastly.

 

[SNT Gatchaman]

There's a Woody Allen movie in there somewhere.

Hopefully the screenwriters can spell better than these authors.

 

[Sean]

The one great benefit seems to be for medical professionals, as the concept allows the avoidance of feelings of ignorance and inadequacy.

There it is.

The greatest sin in medicine is not being wrong, it is having to admit they don't have an answer. So they will invent the most ludicrous 'explanations' to avoid having to make that admission.

There is certainly psychological and moral pathology in this situation, but not in patients.

 

[rvallee]

In that diagram in post #2 - Etiology

Damn. What century is this? Hell, what millennia are these people stuck in?

 

[rvallee]

Thanks, but I'm not sure if that does answer the question, I think I just know too little about the subject. For homosexuality being viewed as psychological disorder and then treated with "conversion therapy" very similar beliefs were present and there is a Freud connection as well as a connection to other psychoanalysts. But I know absolutely nothing on the detailed history of these terms and how they were connected or used back then.



Aren't these very similar or the same theories to justify "conversion therapy"?

Seems to be more of a common ancestor kind of thing, but fundamentally the ideas and their rationalizations are the exact same, just applied to a different thing. Hence why the 'treatment' is basically the exact same.

 

[rvallee]

There it is.

The greatest sin in medicine is not being wrong, it is having to admit they don't have an answer. So they will invent the most ludicrous 'explanations' to avoid having to make that admission.

There is certainly psychological and moral pathology in this situation, but not in patients.

It really is all projection. All of it. Every single part of psychosomatization is pure projection. The illness beliefs. The being unable to accept biological explanations. The reattribution to alternative causes. The internal conflicts and frustration at being told "you're wrong". Even the accusations of bullying. About people who have zero power. Every. Single. Bit. Is. Projection.

And on the subject of gay conversion therapy sharing the same roots, you can read all over what the worse bigots are saying and it's hard to escape how they themselves are often dealing with those urges and have to keep them in check through willpower, can't imagine that other people aren't going through the same. And of course the role of abuse of power, whether religious power through shame in community, or through actual legally-enforced authority.

 

[Hutan]

I found the whole paper eye-opening. I wasn't sure how much I could include on this site, but it is definitely worth a read.

'Eye-opening' as in 'utterly incredible that people in this century believe this sort of Freudian codswallop'? It's fine to quote sentences or paragraphs to make a point.

It's the same standard of thinking as 'she didn't want to hear what the world was telling her, so she got ear-ache' and 'let's treat what seems to be a heart problem with those heart shaped leaves (doctrine of signatures).
A quote from that linked article on the doctrine of signatures applies just as well to the conversion disorder theory:

The doctrine of signatures was of course totally undone by a dash of common sense and more rigorous experimental standards as science evolved. So we certainly, certainly, don’t have any business propagating the theory in 2014. Yet it’s happening. Leading people to believe that they can treat depression by eating walnuts because they look like brains is dangerous and irresponsible, just like saying homeopathy can treat, oh I don’t know, anything at all. These are dead theories, and their rotting corpses must be buried to keep them from stinking up the place.

 

[Jonathan Edwards]

and 'let's treat what seems to be a heart problem with those heart shaped leaves (doctrine of signatures).

From what I can see digitalis was used formal sorts of things as far back as 1250 but mostly for dropsy, which I doubt was linked specifically to the heart until quite a bit later. Even Withering saw it as a means of treating dropsy - assuming an effect on the kidneys through diuresis. He knew it slowed the pulse but the relation between that and oedema was probably not clear until Starling.

The odd thing is that by 1980 it had been established that digitalis is only really much use for dropsy when there is rapid atrial fibrillation. The fact that it had even been identified as curing dropsy may I guess have been because alcoholic cardiac disease with AF may have been the commonest cause of dropsy around 1200-1800 when alcohol was a major source of calories in winter for a good part of the population and coronary artery disease probably had not taken hold until tobacco took over.

 

[Hutan]

Here's a paragraph from the paper worth quoting:

Among adults, women diagnosed with conversion disorder outnumber men by a 2:1 to 10:1 ratio; less educated people and those of lower socioeconomic status are more likely to develop conversion disorder; race by itself does not appear to be a factor.7 There is a major difference between the populations of developing/third world countries compared to developed countries; in developing countries, the prevalence of conversion disorder may run as high as 31 percent.7 Figure 2 illustrates the sociodemographic factors common in conversion disorder.

It strikes me as very much in the vein of 'it's those people over there that have this problem, not those of us who are educated and smart'. Sometimes it is suggested that poor people and people in developing countries don't get functional disorders because they are too busy getting on with survival. But these authors have gone in the other direction, suggesting nearly a third of the population of these countries are converting the feelings they want to repress into physical symptoms. It seems that it does not occur to the authors that substantially lower access to smart doctors with plenty of capacity to undertake sophisticated investigations might increase the rate of 'conversion disorder' diagnoses.

Incidentally, the reference for the 31% of the populations of developing/third world countries? It is the website, The Encyclopedia of Mental Disorders, with an entry that, unlike Wikipedia, does not bother with specific references.

And Figure 2 in this 2015 article? It just puts six risk criteria in circles, arranged around a middle circle with 'sociodemographic correlates'. One of the risks is 'Lack of eduation' (sic).

This stuff and the believers of it, would be laughable if it and they weren't still causing immense harm.

 

[livinglighter]

'Eye-opening' as in 'utterly incredible that people in this century believe this sort of Freudian codswallop'? It's fine to quote sentences or paragraphs to make a point.

It was eye-opening because I am shocked that this is the foundation of thinking for what ME/CFS is being made out to be.

FND is mainly referred to as a 'software' issue as if it's too complex for anyone other than the researchers to understand. Yet, in this paper, it has been clearly explained as symptoms resulting from psychological conflict.

The diagnosis of conversion disorder should be made after establishing positive clinical findings that are incompatible with organic disease or are inconsistent across different parts of the examination19 and after ruling out any medical conditions the symptoms are mimicing.

Figure 3, which serves as diagnostic guidance, asks if neurologic symptoms are inconsistent with a known disease pattern or cannot be explained by neurological or other medical conditions.

Even before the recent claims from Stone et al. that FND is now a rule in diagnosis, most pwME didn't have neurological or other medical conditions that symptoms mimic ruled out. In most cases, neurologists won't see ME patients, and GPs don't make referrals, so where is the high degree of certainty that ME/CFS symptoms are not organic coming from?