The term conversion has been used off and on since the Middle Ages (Mace, 1992) but was popularized by Freud, who believed the anxiety resulting from unconscious conflicts somehow was “converted” into physical symptoms to find expression. This allowed the individual to discharge some anxiety without actually experiencing it. As in phobic disorders, the anxiety resulting from unconscious conflicts might be “displaced” onto another object.
“Functional neurological symptom disorder” is a subtitle to conversion disorder because the term is more often used by neurologists who see the majority of patients receiving a conversion disorder diagnosis, and because the term is more acceptable to patients. “Functional” refers to a symptom without an organic cause.
Conversion disorders generally have to do with physical malfunctioning. Such as paralysis, blindness, or difficulty speaking (aphonia), without any physical or organic pathology to account for the malfunction. Conversion disorders provide some of the most intriguing, sometimes astounding, examples of psychopathology.
In addition to blindness, paralysis, and aphonia, conversion symptoms may include total mutism and the loss of the sense of touch. Some people have seizures, which may be psychological in origin, because no significant electroencephalogram (EEG) changes can be documented. These “seizures” are usually called psychogenic non-epileptic seizures. Another relatively common symptom is globus hystericus, the sensation of a lump in the throat that makes it difficult to swallow, eat, or sometimes talk.
Diagnostic Criteria for Conversion Disorder.
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
Other factors may be more helpful in making this distinction. Conversion symptoms often seem to be precipitated by marked stress. Often this stress takes the form of a physical injury.
But the occurrence of some identifiable stressor has not been a reliable sign of conversion disorder, since many other disorders are associated with stressful events and stressful events often occur in the lives of people without any disorders. Some conversion symptoms involve movements such as tremors that are perceived as involuntary.
More puzzling is a set of conditions called factitious disorders, which fall somewhere between malingering and conversion disorders. The symptoms are under voluntary control, as with malingering, but there is no obvious reason for voluntarily producing the symptoms except, possibly, to assume the sick role and receive increased attention.
When an individual deliberately makes someone else sick, the condition is called factitious disorder imposed on another. It was also known previously as Munchausen syndrome by proxy. In any case, it is really an atypical form of child abuse.
Diagnostic Criteria for Factitious Disorder.
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better accounted for by another mental disorder such as delusional belief system or acute psychosis.
Single episode Recurrent episodes: Two or more events of falsification of illness and/or induction of injury.
Causes of Conversion Disorders.
Freud described four basic processes in the development of conversion disorder.
- First, the individual experiences a traumatic event. In Freud’s view, an unacceptable, unconscious conflict.
- Second, because the conflict and the resulting anxiety are unacceptable, the person represses the conflict, making it unconscious.
- Third, the anxiety continues to increase and threatens to emerge into consciousness, and the person “converts” it into physical symptoms, thereby relieving the pressure of having to deal directly with the conflict. This reduction of anxiety is considered to be the primary gain or reinforcing event that maintains the conversion symptom.
- Fourth, the individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid a difficult situation or task. Freud considered such attention or avoidance to be the secondary gain, the secondarily reinforcing set of events.
Social and cultural influences also contribute to conversion disorder, which, like somatic symptom disorder, tends to occur in less educated, lower socioeconomic groups where knowledge about disease and medical illness is not well developed.
Many conversion symptoms seem to be part of a larger constellation of psychopathology. Linda had broad-ranging somatic symptom disorder, as well as the severe conversion symptoms, that resulted in her hospitalization. In similar cases, individuals may have a marked biological vulnerability to develop conversion disorder when under stress, with biological processes like those discussed in the context of somatic symptom disorder.
Treatment for conversion disorders.
Although few systematic controlled studies have evaluated the effectiveness of treatment for conversion disorders, we often treat these conditions in our clinics. Because conversion disorder has much in common with somatic
symptom disorder, many of the treatment principles are similar.
A principal strategy in treating conversion disorder is to identify and attend to the traumatic or stressful life event, if it is still present (either in real life or in memory).