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Aetiology of conversion disorder

Social processes

Social factors are involved in the development of conversion disorder, at least on some occasions. The condition has been described as contagious, in that the sight or knowledge of one person with unexplained symptoms may trigger similar symptoms in others, particularly in situations where many people are grouped together and placed under some form of stress. One such incident among US Army recruits occurred over a 12-hour period following evacuation of 1800 men from their barracks owing to a suspected toxic gas exposure – which turned out to be a false alarm (Struewing and Gray 1990). Despite the lack of toxin in the atmosphere, over twothirds of the recruits developed at least one respiratory symptom, and 375 were evacuated by air ambulance for immediate medical investigation; 8 were kept in hospital. Two weeks after the incident, 55 per cent of a sample of this group reported developing at least one symptom, including cough, light-headedness, chest pain, shortness of breath, headache, sore throat or dizziness. Those who reported the most, or the most severe, problems reported high levels of physical stress, mental stress, and awareness of rumours of odours, gases and/or smoke.

Psychoanalytic explanations

Early psychoanalytic explanations of conversion disorder considered the condition to refl ect anxiety aroused by unconscious confl ict being converted into physical symptoms. Freud (Freud and Breuer 1984) thought that one ego defence mechanism against high levels of distress was to convert this distress from psychic to physical symptoms. Perhaps the most famous case he reported was that of Anna O, who was initially treated by Joseph Breuer. Anna O was a 21-yearold woman who became ill while nursing her terminally ill father. Her own illness began with a severe cough, and subsequently included paralysis of the extremities of the right side of her body, contractures, disturbances of vision, hearing and language, lapses of consciousness and hallucinations. Breuer noticed that when Anna told him the content of her daytime hallucinations, while under hypnosis, she became calm and tranquil. He considered this to be way of expressing the ‘products’ of her ‘bad self’: a process of emotional catharsis.

Breuer further developed his understanding of her symptoms following a period of time when Anna O stopped drinking, and quenched her thirst by eating fruit and melons. At this time, she recounted in one of her sessions how she had been disgusted by the sight of a dog drinking out of a glass. Soon after this revelation she asked for a drink. Breuer took this to indicate that insight into the factors associated with the beginning of symptoms was a key issue in relieving them. This became a focus of later hypnotic sessions. The twist in the story came from Freud’s analysis of the situation. He noted that Anna specifi cally required Breuer to provide the therapy, and that when she was in a hypnotic state, she needed to feel his hands to ensure he was there. In addition, one of the symptoms she developed was believing that she was pregnant with his child. Freud took this as an indication that she was in love with Breuer – and that her hysterical symptoms were the result of these secret sexual desires. In fact, Freud considered conversion disorder to result from an unresolved Electra complex (see Chapter 2). In this, the young girl is sexually attracted to her father. If her parents’ responses to this are harsh or disapproving, the girl’s feelings are repressed. This leads to a preoccupation with sex, at the same time as an avoidance of it. If these sexual urges occur later in life, the defence mechanism evoked can involve conversion of the sexual impulses into physical symptoms.

Behavioural explanations

The behavioural explanation of conversion symptoms is that they are functional and under the control of the individual expressing them. They are functional in the sense that they lead to some sort of benefi t or reinforcement – the obvious one in the case of the Anna O being the attention given to her by Breuer, while the men in the trenches potentially avoided being killed. In arguing this case, Miller (1999) suggested that it is very diffi cult to determine from an external standpoint what is motivated, controllable, voluntary behaviour and what is not. However, he argued that some notable cases of conversion disorder seem to be faked and under voluntary control – albeit it in a rather clumsy way.

One example of this was reported by Zimmerman and Grosz (1966), who asked a patient with hysterical blindness to identify which one of three visual stimuli was being presented to them. He performed this task at a level consistently below chance – a fi nding that may be considered unusual, because if he was unable to see, he should have performed at chance levels. Zimmerman and Grosz then presented the stimuli in a non-random order (left–centre–right: left–centre–right, etc.), and the person was informed of which stimulus had been presented on each trial following their attempt to identify it. This is a task for which one would expect a blind person to learn the sequence and perform at above-chance levels. The participant in their study

did not. Finally, when he was allowed to overhear a comment by a confederate of the experimenter that ‘the doctors reckon that the patient can see because he makes fewer correct responses by chance than a blind man would make’ (1966: 259), his performance improved to chance levels. Miller speculated that this indicated the individual was dissimilating. This argument can also be made from an anatomical perspective. Merskey (1995) noted, for example, that patients with hysterical aphonia (inability to speak) may be able to cough – yet both processes require the vocal cords to function normally. If an individual can cough, there are no anatomical reasons for them not being able to talk. Similarly, some patients with an inability to move their limbs may show evidence of tensing both the apparently affected muscles and those which prevent movement of the limb. Again, this suggests that some sort of voluntary processes are at work. Despite these cases, Miller (1999) acknowledged these fi ndings do not necessarily mean that all people with these phenomena are faking.

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