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J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(1):7-31
Original Article
Study of Frustration in Adolescents with Conversion Disorder
Narayana Keertish MD, Indira Sharma MD
Address of correspondence: Dr. Narayana Keertish, No. 619, 2nd Cross, RBI Layout,
7th Phase, J P Nagar, Bangalore-560078. Email: [email protected].
ABSTRACT
BACKGROUND: Conversion disorder has been found to be the most common neurotic
disorder in children and adolescents. The relationship between temperament and
conversion disorder is well documented, but there is dearth of Indian studies directed at
studying the psychosocial and temperamental/ personality factors in adolescents with
conversion disorder.
OBJECTIVE: Aim of the study was to assess the reactions of adolescents with
Conversion Disorder to frustrating situations as measured by the Rosenzweig’s PictureFrustration Study.
METHODS: Thirty school going adolescents with Conversion Disorder, diagnosed as
per DSM-IV-TR criteria, and thirty healthy matched controls, comprised the sample.
Patients and controls were assessed by the Rosenzweig’s Picture-Frustration Study.
RESULTS: The patient group was superficially well adjusted, as evident by the Group
Conformity Rating score. However, the patient group was deficient in other areas, both in
the type (higher scores on obstacle dominance) and direction of aggression (lower scores
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on imgression). The patient group also had deficiency in the superego defense patterns
(lower scores on intropunitive deviant and combination of intropunitive deviant and
imgression) and pattern of 3 most frequent responses (higher frequency of extrapeditive
scores).
CONCLUSION: Adolescents with conversion disorder, instead of evading the
frustrating situation, are excessively pre-occupied with the barrier causing frustration.
Thus, efforts to overcome this deficiency should be a part of management of conversion
disorder in adolescents in order to achieve early recovery and to prevent relapse.
KEY WORDS: Conversion Disorder, Adolescents, Frustration
Introduction
Conversion disorder is defined as a deficit of sensory or motor function that cannot be
explained by a medical condition and where psychological factors are judged to be
associated with the symptom or deficit because the initiation or exacerbation of symptom
or deficit is preceded by conflicts or other stressors [1].
Conversion disorder has been found to be the most common neurotic disorder in children
and adolescents [2-6]. Although the incidence and prevalence of conversion disorder is
uncertain, it has been reported to vary from 3%-5% [1,7]. Indian studies have reported
incidence of childhood conversion disorder in up to 31% of inpatient and 14% of
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outpatient samples [8]. Conversion disorder is more often seen in females than in males
[9,10]. Nearly one out of five children will have a behavioural or emotional disorder at
some time in their life [11].
Role of temperamental/personality traits
The relationship between temperament and psychopathology is well documented.
Temperament influences the development and psychopathology in two ways: as a
determinant of psycho-neuro-physiological vulnerability and as a determinant of parentchild interaction in the form of varying the quantity and quality of care evoked by the
temperament of the child [12]. Children with conversion disorder were found to have low
distractibility [13]. Low distractibility may actually mean low soothability i.e. such
children, temperamentally, take longer to come out of a distressed state and remain in
distress for relatively a longer period in the face of day-to-day distress [14].
Ishikura and Tashiro reviewed 9 patients with dissociative disorder and 10 patients with
conversion disorder and found that the patients of both groups, who encountered troubles
in their lives, were found to have frustrated needs [15]. Their symptoms tended to be
accompanied more often by frustrations regarding a 'need for love' in the dissociative
disorder group and by frustration in the need for 'self-esteem and self-actualization' in the
conversion disorder group.
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Psychological investigation of a teenager girl with conversion disorder with mixed
presentation revealed that she had an IQ of 95, rich expressive language, good social
adaptability, low frustration tolerance, egocentrism, a desire to make a good impression
and to be the centre of attention, high suggestibility and histrionic characteristics [16].
The Freudian concept that personality was determined by a dynamic interplay among the
id, ego and superego, supports the idea that conversion symptoms occur as a result of
inability to repress a conflict between the id and the superego [17]. According to
psychoanalytic theory, conversion disorder is caused by repression of unconscious
intrapsychic conflict and conversion of anxiety into a physical symptom. The conflict is
between the instinctual impulse like aggression or sexuality and the prohibitions against
its expression [18].
It is evident from the above review of literature that the temperamental/personality
factors namely; low distractibility, low activity, low emotionality, low frustration
tolerance and the intrapsychic conflict between the instinctual impulse like aggression
(Id) and the prohibition against its expression (Superego), have been implicated in the
causation of conversion disorder in adolescents. Hence, a systematic study of the
reactions to frustrating situations will not only help in understanding the factors that
influence the psychological milieu of children with conversion disorder, but also aid in
planning effective management and prevention of relapse. The present study was
conceived with the aim of studying the nature of frustration (reactions to frustrating
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situations) in adolescents with conversion disorder by Rosenzweig’s Picture-Frustration
Study.
The research hypothesis (H1) for this study was:
There is no significant difference in the nature of frustration of adolescents with
conversion disorder and normal healthy matched controls, on reactions to frustration by
Rosenzweig’s Picture-Frustration Study.
Methods
Sample
The patient group comprised 30 patients in the age group of 12 to 18 years, diagnosed to
be suffering from conversion disorder as per criteria laid down in DSM-IV-TR
(American Psychiatric Association, 2000), who attended the outpatient psychiatry section
(adult and child) of the University Hospital, Banaras Hindu University, Varanasi, India,
Varanasi from March 2008 to July 2009. Patients with co-morbid psychiatric illness or
major general medical condition, Intelligence Quotient (IQ)/ SQ (Social Quotient) of less
than 70 and those not going to school were excluded from the study.
The control group comprised an equal number of apparently healthy children and
adolescents matched with the patient group on age, sex, socio-economic status, domicile
and educational status. Children and adolescents with a score of 10 or more on the
Childhood Psychopathology Measurement Schedule [19], IQ/ SQ of less than 70 and
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those not going to school were excluded from the study. Consent was taken from parents
/guardian and children from both the groups to participate in the study.
The Indian adaptation of the Rosenzweig Picture Frustration study [20] was used to study
the nature of frustration in adolescents with conversion disorder. The Rosenzweig
Picture- Frustration study is a controlled projective technique, primarily intended to
measure reactions to frustrating situations. It was developed as a result of experiments
with repression and frustration carried out by Rosenzweig [20].
The Rosenzweig Picture-Frustration study was adapted and standardized for use in India
by Udai and co-workers [20]. While preparing the Indian adaptation, care was taken to
retain the original situations with as little modification as necessary to make the situations
acceptable in the Indian culture. It is intended for use with adults, but can be used with
adolescents also. The scoring reliability was quite high, the percentage of agreement
increasing to 98% after discussions [20]. Stability co-efficients ranged from 0.27 to 0.82
and consistency values from 0.46 to 0.74.
Methodology
Each patient was assessed in detail on a structured proforma which had items related to
socio-demographic data, psychiatric history, and physical and mental status examination.
IQs/ SQs of the adolescents were assessed with Bhatia Battery of intelligence [21] or
Vineland Social Maturity Scale [22].
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Each patient and control was assessed by the Indian adaptation of the Rosenzweig
Picture-Frustration study. The study consists of 24 cartoon like drawings representing
frustrating situations. In each of the pictures 2 people are shown talking. The words said
by one person are given. The subject is required to imagine what the other person in the
picture would answer in that situation. The very first reply that comes into the mind is to
be told or written. The subject is to work as fast as he can.
General principles of the study
It is assumed as a basis for P-F study that the subject unconsciously or consciously
identifies himself with the frustrated individual in each pictured situation and projects his
own bias in the replies given. Scores are assigned to each response as to the direction and
type of aggression.
Directions of aggression
Directions of aggression included are:
1) Extragression or E-A- in which the aggression is turned on the environment
2) Introgression or I-A- in which it is turned by the subject upon himself;
3) Imgression or M-A- in which aggression is evaded in an attempt to gloss over the
frustration.
Types of aggression
Types of aggression included are:
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1) Obstacle Dominance or O-D- in which the barrier occasioning the frustration stands
out in the responses
2) Ego Defence or E-D- in which the ego of the subject predominates
3) Need Persistence or N-P- in which the solution of the frustrating problem is
emphasized.
Group Conformity Rating (GCR) is a measure of conformity of an individual score to the
modal responses of his group. It may be regarded as “one measure of the individual’s
adjustment to a normal group.” The total E-D score may be said to represent strength or
weakness of the ego, while the N-P score may show adaptive adequacy.
Super ego factors and patterns
Superego (S-E) patterns were calculated to provide a measure of a subject’s
“defensiveness”. The superego deviants E and I were considered in relation with factors
E and I and the category M-A. E is a variant of extrapunitive (E) in which the subject
aggressively denies that he is responsible for some offense with which he is charged. I is
a variant of intropunitive (I) in which the subject admits his guilt, but denies any essential
fault by referring to unavoidable circumstances. M-A (Imgression) refers to evasion of
aggression in an attempt to gloss over the frustration.
Trends
Trends are change of response types with recognizable consistency to any other mode,
and even to change back again or to some third kind of behaviour before reaching the
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end. The formula for calculating the value of the trend is (a-b)/ (a+b), in which ‘a’ is the
amount of factor in the first half of the test and ‘b’ is the amount of factor in the second
half. The total number of possible trends is 15, of which each may be positive or
negative.
1) E’, I’, M’
2) E, I, M
3) e, i, m
4) E-A, I-A, M-A
5) O-D, E-D, N-P
Trends which were not significant as per the significance table given in the manual were
reported as ‘None’.
Total Pattern
In calculating the total pattern, the three factors occurring most frequently, regardless of
the type or direction of aggression, were entered in the order of their frequency and
related to each other by symbols greater (>), lesser (<) or equal (=). Subsequently, the
frequency of the three most commonly occurring factors were tabulated separately for the
control and the patient group.
Comparisons were undertaken on the nature of frustration on the Rosenzweig’s study
between the adolescents with conversion disorder and the control subjects. Chi-square
and Independent samples student t tests were used for the statistical analysis.
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Results
I.
Sample characteristics:
Majority of patients were females and Hindus with rural background. All of them
were unmarried and educated. Due to rapid economic growth in recent past, it was
considered appropriate to classify socio-economic status (SES) based on per-capita
income. About half of the patients hailed from low and low middle SES. The
remaining patients were from higher SE strata. There was no significant difference
between the patient and the control groups on sex, domicile, marital status, religion
and SES (table 1A).
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There was no significant difference between the patient and control groups with
regard to age and years of schooling (table 1B).
II.
Clinical characteristics of the patient group:
The mean age of onset of illness was 15.05 (range = 9-18) years. Patient group had a
mean duration of illness of 32.92 (range= 1-260) weeks. 93.3% (N=28) presented as
pseudoseizures, 3.3% (N=1) with gait abnormality and 3.3% (N=1) with mixed
presentation). Major life events occurring in the 4 weeks period preceding the illness
were considered as precipitating factors. Precipitating factors were observed in 56.6%
(N=17) of the patients.
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III.
Comparison of patient and control groups on Rosenzweig’s Picture-Frustration
Study:
Group conformity rating
The mean Group conformity rating (GCR) of the patient group, was modestly high
(mean 61.67 ± 11.13; Range = 42-79). It did not differ significantly from the control
group (table 2).
Direction of Aggression
The mean imgression score of the patient group was found to be significantly lower
than that of the control group (p=0.021). There was no significant difference between
the patient and the control groups on the mean extraggression and introgression
scores (table 2).
Type of Aggression
The mean obstacle dominance score of the patient group was significantly higher than
that of the control group (P=0.023). There was no significant difference between the
mean ego defence and the mean need persistence scores of the patient and control
groups (table 2).
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Compared to the control group, the patient group had a significantly lower mean
values for the super-ego factors/ patterns, I (p=0.033), E + I (p=0.027), and M-A + I
(p=0.003) (table 3).
Trends
In majority of the patients [19 (63%)-30 (100%)], one or more of the trends were
absent ie None. There was no significant difference (p>0.05) between the patient and
the control group on presence of positive (EA & MA) and negative (E, IA, MA, OD
and ED) trends (Table 4), The frequency of other trends was low and did not permit
statistical comparison.
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Total Pattern
It may be noted that 2 or more than 2 factors amongst the 3 most frequent ones, had
equal frequency in some of the subjects. Therefore, the total number of factors shown
in the table is more than 90. When the total pattern of responses was examined it was
observed that the frequency of E’ (extrapeditive score) was significantly higher in the
patients group than in the control group (0.004). There was no significant difference
between the patient and the control groups with regard to other factors.
Discussion
The present study was a modest attempt to study ‘frustration’ in adolescents with
conversion disorder presenting at the outpatient psychiatry Section of the University
Hospital, Banaras Hindu University, Varanasi. The University Hospital caters to a huge
population hailing from Eastern Uttar Pradesh, Chattisgarh, Jharkhand, Bihar, Madhya
Pradesh and even Nepal.
In the present study, reactions to frustrating situations were assessed with the help of
Rosenzweig’s Picture Frustration Study. The test was administered on an individual basis
because of the opportunity it provided for ‘enquiry’, making scoring and interpretation
more reliable.
Group Conformity Rating (GCR) is the measure of conformity of an individual score to
the modal responses of his group. The patient group had modestly high mean GCR
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(61.67), which did not significantly differ from the mean GCR of the control group,
indicating that on this measure the patient group had an adequate level of adjustment.
The patient and the control groups were compared on the direction of aggression in the
sample. It was observed that patients had significantly lower mean imgression (M-A)
score, compared to that of the control group. The extragression (E-A) and the
introgression (I-A) scores did not differ significantly between the groups. This finding
suggests that the patients did not evade the frustrating situation by attempting to gloss
over it. Instead, they either directed their aggression on to the environment (E-A) or
turned the same upon themselves (I-A). These types of reactions to frustrating situations
are indicative of poor adjustment and coping.
Further analysis was done to explore different types of aggression, namely; obstacle
dominance (OD), ego defence (ED) and Need persistence (NP) in the patient and the
control groups (table . 5). The mean OD score of the patient group was found to be
significantly higher than that of the control group. The mean scores of the ED and NP of
the two groups did not differ significantly. This finding indicates that the patients were
excessively preoccupied with the barrier causing frustration, which may indicate
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‘anxiety’ and embarrassment. The OD scores of the patient group were contributed
predominantly by higher E’ scores in the patient group. Extrapeditive (E’) scores are
given for responses in which presence of the frustrating obstacle is insistently pointed
out.
Super-ego patterns are important as they provide a measure of the subject’s
defensiveness, either in denying the commission of the wrong (E), or in repudiating the
reprehensible motivation connected with such behaviour (I) (Udai & Devi, 2006). The
superego deviants were considered in relation to E (extrapunitive), I (intropunitive) and
the category M-A (imgression). M-A and I were considered together as superego pattern,
as both involved absolution from blame by either excusing someone else or by excusing
oneself.
It was interesting to note that the intropunitive deviant (I) was significantly lower in the
patient group when compared to the control group. The E (extrapunitive deviant),
however, did not differ significantly between the two groups. It follows that the patient
group had weaker superego. While the control group admitted guilt, but denied any
essential fault by referring to unavoidable circumstances, the same pattern was observed
to a much lesser extent in the patient group. When I and E were considered together,
similar findings were observed with patients having lower mean score than the control
group. This was mainly because of the higher mean I score in the controls. Also, patient
group had significantly lower scores compared to the control group when a combination
of M-A and I were considered. This again suggests that superego defences of the patients
are weaker when compared to that of controls.
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As it is possible for subjects to change with recognizable consistency to any other mode,
and even to change back again or to some third kind of behaviour before reaching the
end, the protocols of the patients and controls were analysed for any significant trends.
Five different types of trends, with total 15 trends, each of which could be positive,
negative or none, mentioned in the foregoing chapter, were examined. A positive trend
(←, away from) is one in which a factor/ category predominates in the first half of the
record; the opposite (→, towards) is a negative trend. Trends not significant were
recorded as ‘none’. In the majority of patients, one or more trends were absent i.e. none.
Among the trends found, there was no significant difference when the patient and the
control groups were compared. This finding suggests that by and large, the responses of
the patients to frustrating situations were consistent as no significant difference was
observed between the responses in the first half of the test compared to the second half of
the Rosenzweig’s Picture-Frustration Study.
The total pattern of responses is significant as it provides information on the three most
frequent responses seen in the subjects. The frequency of E’ (extrapeditive score) was
significantly more in the total pattern of the patients than that of the control group (p =
0.004). There was no significant difference between the patient and the control groups
with regard to other factors. Higher E’ scores indicate that the presence of the frustrating
obstacle was insistently pointed out more frequently by patients than controls. This
finding is in keeping with higher mean score on OD in the patient group.
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Conclusion
Hypothesis H1 is rejected and it is concluded that significant differences exist between
the patient and the control group on reactions to frustrating situations as measured by the
Rosenzweig’s Picture Frustration Study. It was observed that, although the patient group
was superficially well adjusted, as evident by the Group Conformity Rating score, the
patient group was deficient in other areas. The patient group had deficiencies, both in the
type (higher scores on obstacle dominance) and direction of aggression (lower scores on
imgression); superego defence patterns (lower scores on intropunitive deviant and
combination of intropunitive deviant and imgression); and pattern of 3 most frequent
responses (higher frequency of extrapeditive scores). Thus, efforts to overcome the
deficiencies should be a part of management of conversion disorder in adolescents in
order to achieve early recovery and to prevent relapse.
These conclusions of this study are tentative in view of lack of previous comparable data
and limitations mentioned below.
Limitations of the study
1. Since only school going adolescents were selected for the study, the findings in
the Rosenzweig’s P-F Study cannot be generalized for the adolescent population
not attending school.
2. The adult form of the Rosenzweig’s P-F study with adult norms has been used in
this work. However, the authors themselves have mentioned that the same can be
used in adolescents.
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3. Group Conformity Ratings were available only for 12 of the 24 items of the
Rosenzweig’s P-F Study.
Future directions
Special efforts should be made to overcome the above mentioned limitations. Further
work should be directed at studying reactions to frustration in association with
important psychosocial variables such as classroom environment, home environment,
sports/ extracurricular activities and experience of stressful life events, in adolescents
with conversion disorder, for elucidating the psychodynamics of the disorder.
Work attributed to: Department of Psychiatry, Institute of Medical Sciences, Banaras
Hindu University, Varanasi
References
1.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision, First Indian edition. New Delhi: Jaypee
Brothers Medical Publishers (p) Ltd; 2002.
2.
Manchanda M, Manchanda R: Neuroses in children: Epidemiologic aspects. Indian
J Psychiatry 1978, 20: 161-164.
3.
Sharma SN, Bhat VK, Sengupta J: Neurosis in children. Indian J Psychiatry 1980,
22: 362-365.
4.
Saxena S, Pachauri R, Wig NN: DSM-III Diagnostic Categories for ICD-9
Hysteria: a study on 103 cases. Indian J Psychiatry 1986, 28(1): 47-49.
30
5.
Chandra R, Srinivasan S, Chandrasekaran R, Mahadevan S: The prevalence of
mental disorders in school-age children attending a general paediatric department
in southern India. Acta Psychiatr Scand 1993, 87(3): 192-196.
6.
Bisht J, Sankhyan N, Kaushal RK, Sharma RC, Grover N: Clinical Profile of
Pediatric Somatoform Disorders. Indian Pediatr 2008, 45: 111-115.
7.
Akdemir D, Unal F: Early Onset Conversion Disorder: A Case Report. Turk
Psikiyatri Derg 2006, 17:1-7
8.
Srinath S, Bharat S, Girimaji S, Sessadri S: Characteristics of a child inpatient
population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993, 32:
822-825.
9.
Steinhausen HC, Aster MV, Pfieffer E, Gobel D: Comparative Studies of
Conversion Disorders in Childhood and Adolescence. J Child Psychol Psychiatry
1989, 30(4): 615-621.
10.
Spierings C, Pocls PJ, Sijben N, Gabreals FJ, Renier WO: Conversion disorders in
childhood: A retrospective follow-up study of 84 inpatients. Dev Med Child
Neurol 1990, 32: 865-871.
11.
Malhotra S: School Mental Health Programme: Mental Disorders in Children and
Adolescents. First edition. New Delhi: CBS Publishers; 2005:245-251.
12.
Malhotra S, Malhotra A, Varma VK: Temperament differences in children: An
overview: Child Mental Health in India. New Delhi: Mcmillan India Limited;
1992:189-199.
13.
Raghunathan G, Cherian A: Temperament of children and adolescents presenting
with unexplained physical symptoms. Indian J Psychiatry 2003, 45: 43-47.
14.
Malhotra S: Temperament characteristics of children with conduct and conversion
disorders. Indian J Psychiatry 1989, 31(2): 168-172.
31
15.
Ishikura R, Tashiro N (2002). Frustration and fulfilment of needs in dissociative
and conversion disorders. Psychiatry Clin Neurosci; 56 (4): 381-390.
16.
Lupu V (2005). Cognitive -Behavioral Therapy in the Case of a Teenager with
Conversion Disorder with Mixed Presentation. Journal of Cognitive and
Behavioral Psychotherapies; 5 (2): 197-205.
17.
Morgan CT, King RA, Weisz JR, Schopler J: Introduction to psychology. Seventh
edition. New Delhi: Tata McGraw-Hill publishers; 1993: 578-579.
18.
Sadock BJ, Sadock VA: Somatoform Disorders. In: Synopsis of Psychiatry, 10th
edition. New Delhi: Wolters Kluwer (India) Private limited; 2007: 638-642.
19.
Malhotra S, Varma VK, Varma, SK and Anil Malhotra: Childhood
Psychopathology Measurement Schedule: Development and standardization.
Indian J Psychiatry 1988, 30 (4): 325-331.
20.
Udai P, Devi RS, Rosenzweig S: The Indian Adaptation of the Rosenzweig
Picture-Frustration Study. Second edition. Varanasi: Rupa Psychological centre;
2006.
21.
Bhatia CM: Bhatia’s Battery of Performance Tests of Intelligence. Agra: National
Psychological Corporation; 1955.
22.
Malin AJ: Vineland Social Maturity Scale and Manual – Nagpur Adaptation.
Lucknow: Indian Psychological Corporation; 1972.
Dr. Narayana Keertish, Associate Professor, Department of Psychiatry, BGS Global
Institute of Medical Sciences, Bangalore.
Dr. Indira Sharma, Professor and Head of Department and Head of Child and Adolescent
Psychiatry Unit, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu
University, Varanasi.