Conversion Disorder (aka Hysteria)
Created | Updated Feb 9, 2005
Hysterics suffer from reminisces.
-Breur and Freud, Studies in Hysteria, 1895
People can have symptoms of disease for all sorts of reasons. There are medical textbooks full of accounts of the possible disturbances in the body's function due to cancer, infection, immune system disturbances and unhealthy lifestyles.
There is a small but significant subgroup of patients for whom no physical cause serves to explain their symptoms. When there is a presumed psychological explanation for the problem, this is called a somatoform disorder. The most 'classical' and specific of these disorders is called conversion disorder.1
What it is
Somatoform disorders in general, and conversion disorder (or CD) in particular, used to be known as hysteria (from the Greek word for uterus) because it was presumed by the Greeks that the problem originated there. It follows from this that for many years CD was presumed to be exclusively a female disorder. This isn't true, although it is more common in women than in men. It is also more common in those of non-European ethnicity.
CD is, as mentioned above, a recognised subtype of the somatoform disorders and by definition the symptoms are limited to sensory loss or paralysis of one part of the body, or mimic another neurological condition like epilepsy - and presentation of the disorder can vary markedly from one person to the next.
If other problems are evident, or the symptoms are more generalised, the label 'somatisation disorder' is used instead. If the problem is primarily pain or fatigue, these come under a different umbrella (pain and fatigue sydromes, respectively2). If the problem is primarily that of fear of a disease that the patient doesn't have, then the diagnosis is one of hypochondriasis.
Physical causes need to be ruled out, and sometimes conversion disorder has been incorrectly diagnosed when a patient actually had a neurological disease. To make things difficult however, CD can co-exist with another, separate physical disease as well. The symptoms need to have started in the context of severe emotional stress or strain for the diagnosis to be made.
Some examples include a paralysed limb (which can, over time, lead to physical muscle atrophy), so-called 'hysterical blindness', muteness, deafness and 'pseudoseizures'.3 These symptoms can be distinguished from purely physical symptoms by their fluctuating nature and the doctor's inability to correlate them to the effects of any known neurological problem. Practically speaking, they just don't fit into the usual picture for any neurological disorder.
Conversion disorder frequently co-exists with depression and anxiety disorders, and the presence of these sometimes helps to make the diagnosis more likely.
It's important to mention that individuals who have the disorder are not aware of the psychological nature of their symptoms. They are not making up symptoms simply for the purpose of being sick - those who knowingly fake illnesses are known (and dreaded) in hospitals as malingerers.
The Case of 'Anna O' - A Famous Example of Conversion Disorder and its Treatment
This case, treated by Josef Breuer in Vienna and famously written up by Breuer and Sigmund Freud, is a typical case of conversion disorder - although the evidence of Breuer's cure has not been demonstrated by clinical trials.
Anna4 was troubled by (amongst other things) a squint, visual problems and paralysis of the right arm and neck. These symptoms didn't correspond to any known problem with the nervous system, and were somehow linked to her nursing her father through his final illness.
Breuer hyponotised Anna, and in her trance she revealed some of the unconscious motivators behind her symptoms that she was unable to recall under normal circumstances. For instance, after recounting (under hyponosis) that she battled to hold back tears daily in order not to distress her dying father, her squint and visual disturbance resolved. Her paralysed arm was related to a dream in which a black snake attacked her father and she was unable to lift a finger to stop it. Similarly, once she recalled the circumstances which led to the paralysis, the symptoms disappeared.
Breuer and Freud used the case history to help formulate the first completely psychological explanation of hysteria, described below.
What Causes it?
As implied above, psychoanalytic theory states that conversion disorder is due to the alternative, physical expression of a forbidden desire that occurs under extreme stress. The desire is repressed and pushed down into the unconscious due to the stress it causes, where it is turned into a physical symptom as a coping strategy.
In other words, it is an unusual form of stress relief. There is usually a reduction in stress as the physical symptom develops, which is referred to as the 'primary gain'. Also, the advantages of the sick role (care, attention and generally being fussed over) are referred to as the 'secondary gain'. The secondary gain aspect of this theory is similar to learning and sociological theories of CD.
Other schools of thought have come up with alternative explanations for the disorder. New techniques of brain scanning, for instance, show that many people who are prone to CD have impaired signalling between the two cerebral hemispheres in their brain, and their dominant hemisphere is underactive relative to unaffected people. One study has shown that brain insults like tumours, strokes or epilepsy are up to ten times as common in people with CD compared to unaffected people. However, as with so much of this sort of research, it's difficult to tell whether this is the cause of the problem, one of the effects of the problem, or something which commonly happens alongside the problem.
How is it Treated?
In clinical trials, symptoms resolve quickly by themselves in 75% of affected individuals, particularly if the stress has passed and the patient was coping well beforehand.
Confronting patients about their symptoms and telling them to pull themselves together is generally spectacularly counter-productive. On the other hand, encouraging or supporting the symptoms by special treatment should be avoided as well.
Psychoanalysis, cognitive behavioural therapy and brief psychotherapeutic interventions are often used, and hypnosis is sometimes still used as well. Some medications like benzodiazepines (such as diazepam, or Valium) and barbiturates may be useful during the initial management of the disorder. Unfortunately, none of these options have good evidence for their effectiveness.
1So called because psychological stressors are 'converted' into physical symptoms.2And obviously.3These are difficult to describe, so best to say that they look exactly like how most non-medical people think seizures should look. They seldom occur in the absence of an audience.4'Anna's' real name was Bertha Pappenheim. She went on to become a prominent social worker and feminist.
