CONVERSION DISORDER By Dr. Hena Jawaid

Definition Term refers to a condition in which there are isolated neurological symptoms that can not be explained in terms of known mechanism of pathology and in which there has been a significant pathological stressor.

Derivation Hysterikos (Greek)- ‘suffering in the uterus’  hystericus (Latin)  Hysteric (Latin)  hysteria hystericus

Background  Upto 17 th CE – Hysteria is due to abnormal position/function of Uterus  Charcot (1825-’93) identified it as functional disorder of brain that enhances hypnotic ability, existing symptoms can be modified and symptoms can be induced  Pierre Janet ( ) – tendency to dissociation – loss normal integration  Frued in wrote a paper ‘Studies on Hysteria’ – adopted word ‘Conversion’. (Unexpressed emotions to physical symptoms)

DSM IV Criteria  deficits suggest a neurological or other general medical condition  deficit is preceded by conflicts or other stressors  deficit is not intentionally produced or feigned  deficit can not be fully explained  deficit causes significant distress  deficit is not limited to pain or sexual dysfunction, somatization dis.

DSM IV Criteria (cont.)  With Motor Deficit  With Sensory Deficit  With Seizures or Convulsions  With Mixed Presentation

ICD - 10  Clinical features as specified for the individual disorders  No evidence of a physical disorder that might explain the symptoms  Evidence for psychological causation, in the form of clear association in time with stressful events and problems or disturbed relationships

ICD – 10 D. Amnesia D. Fugue Multiple Personality disorder D./Conversion NOS D. Stupor Trance and Possession disorder Ganser’s Syndrome

Classification DSM – IV 1. D. Amnesia 2. D. Fugue 3. D. Identity disorder 4. Depersonalization dis. 5. D. Disorder NOS ICD D. Amnesia 2. D. Fugue 3. Multiple Personality disorder 4. D./Conversion NOS 5. D. Stupor 6. Trance and Possession disorder 7. Ganser’s Syndrome

Epidemiology  Incidence – 5-12/ 100,000  Prevalence – 50/100,000 Reference- Shorter Oxford textbook of Psychiatry – 5 th edn.

Epidemiology (Cont.)  In India, 31% among IP, 6-11% in OP setting  In Turkey among OP 27.2%  In Pakistan -12.4% in OP and 4.8% of the admissions in IP psychiatric units  Females as compared to males (60% vs. 4.20%), middle income group, less education References –  Malik P, Singh P. Characteristics and outcome of children and adolescent with conversion disorder. Indian J Pediatr 2002;39:  Wig NN. A follow up study of hysteria. Indian J Psychiatry 1982;3:50-5.  Pehlivanturk B, Unal F. Conversion disorder in children and adolescents: clinical features and co morbidity with depressive and anxiety disorders. Turk J Pediatr 2000;42:  Malik SB, Bokhari IZ. Psychiatric admissions in a teaching hospital: a profile of 177 patients. J Coll Physicians Surg Pak 1995;9:159-61

Epidemiology (Cont.)  The commonest symptoms among the patient population in Pakistan may be extremely rare in West, unresponsiveness and jerky body movements (pseudo-seizures) – 53% Refrences Conversion Disorder: Difficulties in Diagnosis using DSM-IV/ ICD-10 by Syed EU et al

Etiology  Psychodynamic theories  Social factors  Neuro-physiological mechanisms  Cognitive explanations  Cultural explanations

Neuro-physiological mechanisms  SPECT using (99m)Tc-ECD- decrease RCBF in thalamus & basal ganglia opposite to the deficit.  Lower activation in contralateral caudate during hysterical conversion symptoms predicted poor recovery at follow-up. hysterical conversion deficits may involve a functional disorder in striatothalamocortical circuits controlling sensorimotor function and voluntary motor behavior References - “Functional neuroanatomical correlates of hysterical sensorimotor loss” Brain Jun by Vuilleumier P

Treatment  Reassurance  Immediate efforts to resolve any stressful conflict or event  Should provide healthy alternatives for return to normal functioning  Attention should be directed away from symptoms to resolution of problems  Offer continuing help

Treatment (Cont.)  Medication has no direct play in the treatment  If conversion is secondary – Depression  If conversion is secondary – Anxiety

Prognosis Good  Short history  Young age Bad  Long history  Personality disorder  Receipt of disability benefit

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