Conversion Disorder as One of the Mental Disorders - Essay Example

CONVERSION DISORDER 2007 CONVERSION DISORDER Introduction Conversion Disorder (CD) is one of the five Somatoform Disorders listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fourth Edition (DSM-IV) together with Body Dysmorphic Disorder (BDD), Somatization Disorder (SD), Hypochondriasis (HD), Pain Disorder, and Undifferentiated Somatoform Disorder (USD). CD is characterized by the presence of one or several neurological symptoms (extreme weakness, paralysis, blindness, sensory disturbance, seizure, etc) that cannot be attributed to any currently known neurological or other medical disorder despite bearing much resemblance to known organic conditions such as dystonia or epilepsy (DSM-IV, 1994). Historically, conversion symptoms have been attributed to a wide range of mechanisms. Thus, the Ancient Greeks believed that symptoms currently associated with CD were specific to women, and considered them to be caused by the wandering of the uterus (hustera), from which the word hysteria derives. The first use of the term 'conversion' is attributed to Freud whom referred it to the substitution of a somatic symptom for a repressed impulse or idea. This behavior exemplifies the psychological concept of 'primary gain', i.e. psychological anxiety is converted into somatic symptomatology, which lessens the anxiety and gives rise to the so-called la belle indifference condition, when the person seems unconcerned about its physical symptoms. The 'secondary gain' of such a reaction is the subsequent reward or benefit the person receives as the result of acting in the disordered way (Owens & Dein, 2006). Although the definition and diagnostic criteria for CD provided in the DSM-IV are very detailed many issues associated with this disorder seem to poorly explored and understood as well as its prevalence and etiology. While further research in the field of conversion symptoms is clearly required in order to resolve the controversies and close numerous gaps numerous and often contradictory etiological theories may be highly beneficial for the therapists at this stage: versatility of data opens a number of ways for designing and testing new treatments and interventions for conversion symptoms. Main Body Diagnostic criteria The definition of conversion disorder was historically associated with psychodynamic concepts, particularly in earlier versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The most current definition is found in the 4th edition of the DSM (DSM-IV) and is as follows: A. The presence of symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition; B. Psychological factors are judged to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit; C. The symptom or deficit is not intentionally produced or feigned as in factitious disorder or malingering; D. The symptom or deficit can not be fully explained by a neurological or other general medical condition, by the direct effects of a substance, or as a culturally sanctioned behavior or experience; E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation; F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder (DSM-IV, 1994: 452). These diagnostic criteria are not accepted by all professionals working in the field: many psychiatrists prefer to use the International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria, which classifies CD as a Dissociative Disorder (DD) (Looper & Kirmayer, 2002). In DSM-II CD was also included in the DD category, but in the next two revisions of the Manual CD is placed with the Somatoform disorders due to the fact that the presence of psychological factors is not observed initially while somatic presentation is primary. However, the fact that two of the most widely recognized and respected diagnostic manuals do not share the same view in classification of CD demonstrates that there is still no full consent regarding the disorder among the experts. Prevalence The lack of full clarity about the diagnostic criteria of CD may contribute to serious variations in prevalence of this disorder reported by different sources. Thus, Kaplan and Sadock (1998) report that though the lifetime prevalence of conversion symptoms (not the full disorder) is rather high at approximately 30%, the incidence of CD in the general population about 22/100,000. However, in a more recent study Looper and Kirmayer (2002) report another figure claiming that the incidence of CD ranges from 11 to 31/100,000 while in medical settings the prevalence varies from 0.7 to 5%. The disorder is not distributed equally among genders: the incidence in female population is reported to be considerably higher than in males with the ration of approximately 2-5:1 (Kaplan & Sadock, 1998). In male population, most commonly CD occurs in boys aged from 10 to 15 year (Leary, 2003). In female population CD commonly occurs in young women, and it is very rare in children under 8 years old (Owens & Dein, 2006). CD may occur at any age, but its incidence tends to decrease with age (Kaplan & Sadock, 1998). Racial and ethnic distribution of CD has not been comprehensively explored yet. Although some studies report that the prevalence of these symptoms commonly tends to be higher among representatives of ethnic minorities in the US, there is a clear lack of reliable empirical data to support this statement (Owens & Dein, 2006). Although the data coming from European, Asian, and African countries demonstrates very different incidence of CD (Powsner & Dufel, 2006) in population with dissimilar racial and ethnic background the difference can probably be attributed to statistical errors or other factors (for example, culturally differences in behavior). Residence and several other social factors are also reported to relate to the incidence of CD. Thus, the incidence of CD and conversion symptoms is more common in rural areas than in cities, and the disorder is met more often among people with low income, low level of education, and low IQ. Also, it is more commonly met among people whom participated in combat (Kaplan & Sadock, 1998). Etiology Etiology of CD is not fully clear up to date: there are three major perspectives that seek to explain the origins of the disorder. The psychoanalytic perspective stresses unconscious impulses (sexual or aggressive) and the conscious prohibition to express them (Kaplan & Sadock, 1998). This perspective is based on the classic case of Anna O. described by Sigmund Freud in the late 19th century. From this perspective, physical symptoms associated with CD allow the person to partially express the unconscious impulses. The learning perspective is based on the assumption that human behavior is shaped by the environment. Consequently, the symptoms associated with CD are perceived as maladaptive behaviors used by the person to produce some reinforcing consequences also known as secondary gains. The disorder is then sustained by the effects of these behaviors (McHugh & Slavney, 1998: 223-237). And finally, the sociocultural perspective postulates that many cultures across the globe do not allow their members to directly express direct intense emotions. Such prohibition is likely to predispose people to exhibit the symptoms associated with CD as a more acceptable form of communication. From this perspective, CD allows people to express the forbidden feelings non-verbally. The prohibitions are often reinforced by religious beliefs, gender roles or other sociocultural influences cultivated in the society (Schwartz et al, 2001). Furthermore, the recent advances of neuroscience revealed some previously unknown biological and neuropsychological factors that may contribute to the development of CD. Thus, hypometabolism of the dominant hemisphere and hypermetabolism of the non-dominant hemisphere, excessive cortical arousal, elevated levels of corticofugal output, impaired hemispheric communication and several other abnormalities are reported as the causes of the disorder in the recent research (Kaplan & Sadock, 1998). Presence of CD symptoms in children from families members of which have a history of conversion suggests the disorder may have genetic nature. Many credible studies confirm high incidence of other disorders such as depression, ADD, and other personality disorders in patients with CD, which also contributes to the difficulties in defining etiology of the disorder (Powsner & Dufel, 2006). Prognosis One of the first studies investigating the prognosis for recovery from CD was carried out more than four decades ago. Elliott Slater (1965) conducted a 10-year follow-up study of patients with distinct CD symptoms to find out than more than 50 percent would develop psychiatric or neurological conditions at follow-up. Although Slater's findings have been confirmed by a series of later studies more recent research lean toward more optimistic prognosis: the discrepancy between the high rates of neurological disorders reported in studies similar to Slater's one and the lower rates reported in later studies may be caused by methodological issues and incorrect analysis of data (Owens & Dein, 2006). Almost 100 percent of patients with CD symptoms are able to successfully eliminate them during a short period of time from several days to one month. Only 25 percent of such patients may experience additional episode of CD during periods of psychological stress while 7 percent are reported to have no relapse. The primary factor associated with negative prognosis is continuance of the symptoms; factors associated with positive prognosis are acute onset, an easily identifiable stressor and absence of comorbid psychiatric or medical conditions (Kaplan & Sadock, 1998). The latter represent of the most essential challenges because complete medical and neurological examination is not always performed in patients with CD. Treatment Since the etiology of CD is not fully clear there are several approaches in treatment of this disorder. The choice of approach largely depends on which view of CD is perceived as correct by the therapist and patient. For example, the psychoanalytic perspective implies that the therapist must treat the disorder by helping the patient overcome the conflict between unconscious drives and internalized prohibitions. This can be achieved by psychoanalysis and insight-oriented psychotherapy with the patient attempting to identify the internal conflict and understand the symbolism of the symptoms associated with CD (Kaplan & Sadock, 1998). The therapeutic implications of the learning perspective imply that it is very essential to change the patient's maladaptive beliefs by means of countersuggestion and to take psychosocial measures to reduce the benefits or gains associated with the patient's inclination to express the symptoms associated with CD. The aim of this approach is to ensure that the patient receives more benefits from relinquishing the symptoms than from maintaining them. And finally, the sociocultural perspective allows for the expression of normally suppressed intense feelings or emotions in certain rituals accepted within their culture (Owens & Dein, 2006). Although the choice of treatment may be different in each particular case, the integrative approach to treating CD becomes increasingly popular these date. This approach combines cognitive, behavioral, physiological, and pharmacological methods used simultaneously to enhance each other and cope with the disorder more effectively (Spratt & Demaso, 2006). Hypnosis, Eye Movement Desensitization and Reprocessing (EMDR), family therapy and several other alternative treatment methods can also be used in treatment of CD though not convincing evidences are available to show their effectiveness. Thus, a typical treatment plan must include at least two equally important steps. Firstly, the therapist is supposed to acknowledge that the patient does have the symptoms of conversion that negatively affect his life. The earlier the patient is diagnosed the more chances for rapid recovery with positive long-term prognosis he has. At this stage it is also very important to correctly identify any other psychological or neurological disorders that tend to co-occur with CD (for example, ADD or depression). Granted the etiological controversy associated with the disorder the therapist should eliminate any bias in identifying the causes of CD in each particular case: the disorder is likely to have multiple etiologies and, therefore, viewing all cases from any single perspective (either psychoanalytic, genetic, biological, learning or other) is not appropriate Secondly, on the basis of comprehensive examination of the patient the therapist must design a treatment program. Depending on the causes of CD the program may include variety of methods and techniques. As it has already been mentioned, success of the intervention can be achieved through several different approaches. Many researchers believe that a graded physiotherapy program linked to a reward system and directed by an empathic physiotherapist is the most effective intervention strategies. However, other strategies such as behavioral therapy (both positive and negative reinforcement), psychoanalysis and hypnosis are also reported to be effective though they are more time-consuming and require further research to confirm their effectiveness (Leary, 2003). The therapist also should take into consideration the comorbid disorders and use any applicable means (pharmacological or non-pharmacological) to treat them simultaneously with CD symptoms in order to improve the long-term prognosis. Thirdly, professional implementation of the chosen intervention strategy and follow up of the patient must be ensured by the therapist. In case the therapist observes that the patient does not respond adequately to the treatment the program must be modified to achieve the best outcomes possible. The follow up helps prevent relapse of the disorder. Although resolution of CD symptoms typically occurs spontaneously (Kaplan & Sadock, 1998), correctly chosen and professionally implemented intervention strategy is likely to improve the outcomes and long-term prognosis for recovery from the disorder. Conclusion Although the incidence of CD symptoms is higher than the incidence of many other disorders (for example, developmental disorders such as autism) the level of our knowledge about CD is still rather low. Moreover, the existing research in the field of CD is rather controversial with neither of the numerous etiological perspectives providing the comprehensive explanation: true etiology is still unknown though majority of researchers presume that conversion symptoms are caused by inner conflict, emotional stress or comorbid psychiatric disorders. However, versatile and often contradictory information coming from different sources is of great help for the clinicians. Firstly, up to now there is no clear answer as to what type of therapy is the best in each particular case, but it is already clear that the choice of effective treatment may and should seriously vary from person to person. Comprehensive versatile knowledge about the origins, symptoms and consequences of conversion symptoms will result in more informed choices regarding therapy's road to improvement. Besides, effectiveness of some existing therapies and intervention strategies in coping with CD symptoms is either questioned or still remains poorly explored. Alternative perspectives on etiology of conversion symptoms provide a basis for new therapies such as hypnosis, EMDR or family therapy. And finally, the variety of data generated by representatives of different approaches may be very helpful in designing new highly effective interventions which can be addressed as perhaps the most promising trend in treatment of CD symptoms. Therefore, further research is needed to examine etiology of CD, its prevalence in various populations of patient and to explore the effectiveness of different modes of treatment for conversion symptoms. References American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (Fourth edition) (DSM-IV). Washington, DC: American Psychiatric Association, 452-457. Leary, P. M. (2003). Conversion disorder in childhood-diagnosed too late, investigated too much Journal of the Royal Society of Medicine 96, 436-438. Looper, K. J. & Kirmayer, L. J. (2002). Behavioral Medicine Approaches to Somatoform Disorders. Journal of Consulting and Clinical Psychology 70(3), 810-827. Kaplan, H. I. & Sadock B. J. (1998). Somatoform Disorders, in Synopsis of Psychiatry, 8th Edition. Baltimore, Md.: Williams and Wilkins, 629-645. McHugh, P. R. & Slavney, P. R. (1998) The Perspectives of Psychiatry (2nd edition). Baltimore, MD: John Hopkins University Press. Owens, C. & Dein, S. (2006). Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment 12, 152-157. Powsner, S. & Dufel, S. (2006, July). Conversion Disorder [Electronic version]. E-Medicine [available online at http://www.emedicine.com/EMERG/topic112.htm] Schwartz, A., Calhoun, A., Eschbich, C. (2001). Treatment of conversion disorder in an African American Christian woman: cultural and social considerations. American Journal of Psychiatry, 158, 1385-1391. Slater, E. (1965). Diagnosis of hysteria. British Medical Journal 1, 1395-1399. Spratt, E. G. & Demaso, D. R. (2006, May). Somatoform Disorder: Somatization. E-Medicine [available online at http://www.emedicine.com/ped/topic3015.htm] Read More