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What is conversion disorder

 Long known as hysteria or hysterical conversion, the American Psychiatric Association now calls this condition conversion disorder. DSM-IV-TR provides the diagnostic criteria for this diagnosis:

One or more symptoms or deficits affect voluntary motor or sensory function that suggest a neurological or other general medical condition.

Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or defi cit is preceded by conflicts or other stressors.

The symptom or deficit is not intentionally produced or feigned.

The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience.

People with conversion disorder often present with striking neurological symptoms such as weakness, lack of coordination, paralysis, sensory disorders or memory loss, in the absence of any medical pathology. Less common symptoms include somatosensory disorders and skin changes. Many people appear unconcerned about their symptoms – a characteristic sometimes labelled la belle indifférence. Perkin (1989) estimated that up to 4 per cent of those attending neurology outpatient clinics in theUnited Kingdomhave conversion disorders. Benbadis and Allen Hauser (2000) estimated that 10 – 20 per cent of patients referred for treatment of epilepsy in theUSAhad what they termed ‘psychogenic non-epileptic seizures’. The prevalence of conversion disorders within the general population is harder to estimate.

However, Favarelli et al. (1997) found a rate of 0.3 per cent among a relatively small population sample of 673 individuals. It also has high co-morbidity. Crimlisk and Ron (1999) estimated that up to 50 per cent of people with conversion disorder could be assigned a second diagnosis of depression: up to 16 per cent could be assigned a diagnosis of anxiety. The prognosis is not good. Crimlisk et al. (1998) followed 73 people with medically unexplained motor symptoms for six years. Only three people were given a medical diagnosis, indicating an initial misdiagnosis, in this time. Seventy-fi ve per cent were diagnosed with a ‘psychiatric disorder’; 45 per cent were diagnosed with a personality disorder. The presenting symptom was unchanged in 14 per cent, and had worsened in 38 per cent. Interestingly, Ahmad et al. (2008) found the rate of admissions to hospital with a diagnosis of medically unexplainable stroke symptoms varied according to the phase of the moon. Over a period of 13 years, admissions were higher during a full moon than at other times. They offered no explanation. On an equally bizarre note, Burneo et al. (2003) noted that a key diagnostic feature of the disorder was what they termed ‘the teddy bear’ sign: 87 per cent of the 903 cases they reported on brought a teddy bear to the diagnostic testing process. The term hysteria originally derived from the Greek word for uterus. Initially, it was used to label a condition thought to occur as a result of the uterus literally wandering through the body, resulting in symptoms as varied as feelings of suffocation, dramatic fi ts, paralysis of the limbs, fainting spells, sudden inability to speak and inability to take in food. Treatment involved encouraging the womb back to its proper place through physical manipulation. More recently, the condition came to prominence in the First World War, when many soldiers in the trenches developed a condition known as ‘shell shock’, of which the most prominent features were blindness, paralysis, contractures, aphonia, anaesthesias and profound amnesias.

The initial interpretation of these symptoms was that they resulted from micro-haemorrhaging in the brain, as a consequence of the shock created by exploding shells – hence the term ‘shell shock’. Subsequently, doctors noted that the majority of soldiers with the condition had not been close to any explosions, there was no evidence of any brain haemorrhages among those who had died and been subjected to autopsy, and the condition occured among recruits who had not yet been in battle. As a result of this, the condition became thought of as psychological rather than physical. Interestingly, social and cultural factors appear to have infl uenced both development and treatment of shell shock. Offi cers were less likely to develop these problems than enlisted men, but when they did they were more likely to be taken from the trenches and receive long-term treatment, even when their symptoms were relatively minor.

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