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Conversion Disorders Among out Patients Attending Altigani Almahi Psychiatric Hospital During (2003-2008). SUDAN A Thesis submitted to the University of Khartoum for Partial fulfillment of M.A in clinical psychology Submitted by: Salha Mhadi Alhassan Ahmad B.Sc. in Psychology and Pre-School Education Ahfad University1986 Diploma in Clinical Psychology Khartoum University 2003 Supervisor: Dr. Abdelbagi Dafa Allah Ahmed Department of Psychology - Faculty of Arts October (2009) Dedication I dedicate this work to: My Dear Mother: Syda My daughters Dr.Rehab – Ferdos – Sara –Suzan and youngest sweet shemaa My Dear husband: Dr. Magrabi Finally: I would like to dedicate this work to all people who suffer the stigma of mental (health) in Sudan. I Acknowledgement First , thanks are due to Allah for help and support , There after I would like to express my deep gratitude to ,my supervisor Dr Abdel bagi Dafa Allh Ahmed for his inspiring advices and calm full support , My thanks extended to all those who helped me in deferent ways, particularly: Dr. Abeer Abdu Alrhman who teach me how to think critically and give me the technique to conduct research, my teachers were definitely my real back support. Dr. Rugaia Elsyed Eltaib.. Dr. Amal Ata Elseed Dr Suliman Ali Ahmed Dr . Yousif Safi Eldeen. Dr. shams Eldeen. Dr. Salah Haroon. Dr Abd Allh Abd Alrhman Special thanks to Altigani Almahi psychiatric hospital members. Finally I would like to thanks Khartoum University – Faculty of Art , Department of Psychology for giving me this greatest chance to be a member of this department as a student of post graduate studies – and thanks to all my teachers in all semesters First and finally thanks to God. II Abstract Salha Mhadi Alhassan Ahmad Conversion disorder Among outpatient Attending Altigani Almahi psychiatric hospital during (2003-2008) This study tries to investigate the relationship between conversion disorders and age ,gender , educational level ,socioeconomic status and marital status of outpatient attending the Altigani Almahi psychiatric hospital located in Omdurman (Khartoum state ) . The research is retrospective , the sample size include all records of outpatient diagnosed as conversion disorders patient of total of (100) subjects during (2003-2008) their ages range between (11-55) years , the data was manipulated by the computer applying the statistical package for social sciences (spss) using chi-square tests . The result of the study show no significant correlation between age , marital status, educational level , gender and symptoms of conversion disorder . The result of the study show that there is significant positive correlation between socio-economic status and symptoms of conversion disorder . The important recommendation of this research is to higher the socio-economic status of the population to decrease the incidence of conversion disorders symptoms by decreasing the predisposing factors . III ﻣﺴﺘﺨﻠﺺ اﻟﺪراﺳﺔ ﺻﺎﻟﺤﺔ ﻣﻬﺪي اﻟﺤﺴﻦ أﺣﻤﺪ اﻹﺿﺮاﺑﺎت اﻟﺘﺤﻮﻟﻴﺔ وﺳﻂ اﻟﻤﺮﺿﻰ اﻟﻤﺘﺮددﻳﻦ ﻋﻠﻰ اﻟﻌﻴﺎدة اﻟﺨﺎرﺟﻴﺔ ﺑﻤﺴﺘﺸﻔﻰ اﻟﺘﺠﺎﻧﻲ اﻟﻤﺎﺣﻲ ﺑﺈﻣﺪرﻣﺎن )وﻻﻳﺔ اﻟﺨﺮﻃﻮم( ﻓﻲ اﻟﻔﺘﺮة ﻣﺎ ﺑﻴﻦ )(2008-2003 هﺪف هﺬا اﻟﺒﺤﺚ ﻟﺪراﺳﺔ اﻟﻌﻼﻗﺔ ﺑﻴﻦ أﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ وآﻞ ﻣﻦ اﻟﻨﻮع،اﻟﻌﻤﺮ ،اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋﻴﺔ و اﻟﻤﺴﺘﻮى اﻻﻗﺘﺼﺎدي ،وﺳﻂ ﻣﺮﺿﻰ اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ اﻟﻤﺘﺮددﻳﻦ ﻋﻠﻰ اﻟﻌﻴﺎدات اﻟﺨﺎرﺟﻴﺔ ﻟﻤﺴﺘﺸﻔﻰ اﻟﻄﺐ اﻟﻨﻔﺴﻲ ﺑﺄم درﻣﺎن ﻓﻲ اﻟﻔﺘﺮة ﻣﻦ ﻣﺎﻳﻮ 2003وﺣﺘﻰ دﻳﺴﻤﺒﺮ . 2008 اﺳﺘﺨﺪﻣﺖ اﻟﺒﺎﺣﺜﺔ اﻟﻤﻨﻬﺞ اﻟﻮﺻﻔﻲ واﺷﺘﻤﻠﺖ ﻋﻴﻨﺔ اﻟﺪراﺳﺔ آﻞ اﻟﺴﺠﻼت اﻟﺘﻲ ﺷﺨﺼﺖ أﻓﺮادهﺎ ﺑﺄﻧﻬﻢ ﻣﺼﺎﺑﻮن ﺑﺎﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ واﻟﺬﻳﻦ ﺑﻠﻐﺖ ﺟﻤﻠﺘﻬﻢ 100 ﻣﺮﻳﺾ ،ﺗﺮاوﺣﺖ أﻋﻤﺎرهﻢ ﻣﺎ ﺑﻴﻦ ) (55-11ﻋﺎﻣﺎ .ﺗﻤﺖ ﻣﻌﺎﻟﺠﺔ اﻟﺒﻴﺎﻧﺎت ﺑﺎﺳﺘﺨﺪام اﻟﺤﺰﻣﺔ اﻹﺣﺼﺎﺋﻴﺔ ﻟﻠﻌﻠﻮم اﻻﺟﺘﻤﺎﻋﻴﺔ ،وذﻟﻚ ﺑﺎﺳﺘﺨﺪام اﺧﺘﺒﺎر ﻣﺮﺑﻊ آﺎي .وﻗﺪ ﺗﻮﺻﻠﺖ اﻟﺪراﺳﺔ ﻟﻤﺠﻤﻮﻋﺔ ﻣﻦ اﻟﻨﺘﺎﺋﺞ اﻟﻤﻬﻤﺔ ﻣﻦ أﺑﺮزهﺎ ﺗﻮﺟﺪ ﻋﻼﻗﺔ داﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ اﻟﻤﺴﺘﻮى اﻻﻗﺘﺼﺎدي وإﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ وﺳﻂ اﻟﻤﺮﺿﻰ اﻟﻤﺘﺮددﻳﻦ ﻋﻠﻰ اﻟﻌﻴﺎدة اﻟﺨﺎرﺟﻴﺔ .ﻻ ﺗﻮﺟﺪ ﻋﻼﻗﺔ داﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ اﻟﺤﺎﻟﺔ اﻻﺟﺘﻤﺎﻋﻴﺔ وإﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ وﺳﻂ اﻟﻤﺮﺿﻰ .ﻻ ﺗﻮﺟﺪ ﻋﻼﻗﺔ داﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ اﻟﻌﻤﺮ وإﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ .ﻻ ﺗﻮﺟﺪ ﻋﻼﻗﺔ داﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ اﻟﻤﺴﺘﻮى اﻟﺘﻌﻠﻴﻤﻲ وأﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ .ﻻ ﺗﻮﺟﺪ ﻋﻼﻗﺔ داﻟﺔ إﺣﺼﺎﺋﻴﺔ ﺑﻴﻦ اﻟﻨﻮع وأﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ. ﻳﻮﺻﻲ اﻟﺒﺎﺣﺚ ﺑﺮﻓﻊ اﻟﻤﺴﺘﻮى اﻻﻗﺘﺼﺎدي ﻟﻠﺴﻜﺎن ﻟﺘﻼﻓﻲ اﻟﻌﻮاﻣﻞ اﻟﻤﺴﺎﻋﺪة ﻟﻈﻬﻮر أﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ وﻳﻮﺻﻲ ﺑﺒﺤﻮث ﻓﻲ ﻧﻔﺲ اﻟﻤﺠﺎل ﺗﻀﻢ آﻞ اﻟﻤﺴﺘﺸﻔﻴﺎت واﻟﻤﺮاآﺰ اﻟﺼﺤﻴﺔ اﻟﺘﻲ ﺗﺘﻌﺎﻣﻞ ﻣﻊ اﻟﻤﺮﺿﻰ ذو أﻋﺮاض اﻻﺿﻄﺮاب اﻟﺘﺤﻮﻟﻲ IV List of Contents Subject Page - Dedication i - Acknowledgement ii - Abstract in English iii - Abstract in Arabic iv - List of content v viii - List of tables Chapter One 1 1.1 Introduction 1 2 1.2 Objective 2 1.3 General objective 2 2 1.4 Specific objectives 2 1.5 Hypothesis of the research 1.6 Study limitation 3 3 1.7 Study area 3 1.8 Study time 3 1.9 Terminology definition 3 5 Chapter Two V Literature review 5 Etiology of conversion disorders 6 Pathophysiology 7 Diagnostic of conversion disorders and risk factors 11 Childhood traumatization 13 Psychiatric co-morbidity 16 Management 19 Prognosis and course 21 Previous Studies 22 Chapter Three 29 Methodology and procedures 29 Study area 29 Study population 30 Sampling 30 Study design 31 Material and methods 32 Procedures 32 Chapter Four 33 Results and discussion 33 Chapter Five 37 Discussion 37 Chapter Six 43 VI 43 - The conclusion 44 - Recommendation - References & Appendix 45 VII List of tables : Table (1) socio demographic profile of subject page 31 Table (2) gender and conversion disorders symptoms page 33 Table (3) economic status and conversion disorders symptoms page 34 Table (4) age group and conversion disorders symptoms page 34 Table (5) marital status and conversion disorders symptoms page 35 Table (6) education levels and conversion disorders symptoms page 35 Table (7) total number of psychiatric patients attending Altigani Almahi psychiatric hospital during 2007 page 41 VIII CHAPTER ONE 1-1 Introduction: The research problem statement is the relationship between conversion disorder and (age, gender ,educational and socio-economical status, marital status ) considering levels the interest, magnitude ,measurement of concepts ,level of expertise, relevance, availability of data and ethical issues. Mental health is an important part of public health, which is not so considered or talked. The researcher like to highlight on conversion disorders here in the Sudan particularly in Khartoum where The researcher didn't found enough data or research in that area. Socio-demographic profile is any features related to person social character like age, sex, address, and so on. This kind of information are so important to describe any disease and to know which are the risk groups and to give idea about disease predisposing factors . Moreover, in order to do research in any field researchers need to have preliminary data. That the researchers are intending to do here in this study, to give general idea about sociodemographic character of conversion disorders patients here in Sudan. Although this study has its limitation being hospital record based and only including the statement of one center but that will open a door for more comprehensive studies to answer some questions : 1. In which age it is more common? 1 2. Is there any relationship between socio-economic status and conversion disorders? 3. Is there any relationship between the educational level and conversion disorders 4. Which sex is affected more? 5. Is symptoms more common among married or unmarried subjects? 1-2 Objectives: 1-3 General Objective: To determine the socio- demographic profile (age ,gender, martial status, education level..etc) of patient of conversion disorders attending Altigani Almahi psychiatric hospital during a period from January 2003 to December 2008. 1-4 Specific Objectives: - To Identify which sex affected more . - To determine the relationship between the educational level and conversion disorders. - To detect in which age it is more common. - To determine the relationship between socio-economic status and conversion disorders . - To determine the relationship between martial status and conversion disorders. 1-5 Hypothesis of the research: 1. Conversion disorders are more common among females . 2 2. Conversion disorders are more common in low socioeconomic classes . 3. Age group (12-24)years (Adolescents ) are more affected with conversion disorders . 4. Conversion disorders is common among unmarried subjects . 5. Conversion disorders is common among low – educational level . 1-6 Study population: 100 subjects from the records of outpatients. 1-7 Study location: Altigani Almahi psychiatric hospital located in Omdurman city. 1-8 Study time : between 2003 – 2008 1-9 Terminology definition : (a) Conversion disorders: earlier called hysteria, involves a neurotic pattern in which symptoms of some physical malfunction or less of control appear with out any underlying organic pathology. The symptoms of conversion disorders was - seizer – Aphonic etc. (Principles of ambulatory medicines, third edition by L.Randal Borked, R Burton. 1991) . (b) Out patient: The patient who received the treatment out the hospital. (c) Altigani Almahi psychiatric hospital : Located in Omdurman city, Khartoum state capital of Sudan. The hospital consist of causality department with causality ward for 3 short stay, out patient and referral department, E.C.T department, nutrition department and administration department. Altigani Almahi hospital located in Omdurman city Khartoum state capital of Sudan, it accommodate 119 beds in causality department and 107 beds in general wards, there are 14 house officer, 17 medical officer, 10 medical registrar in psychiatry and 7 consultants, patients attending the hospital are about 2500- 3000 patients per year. The hospital consists of causality department with causality ward for short stay, out patient and referral department, E.C.T, department, nutrition department and administration department. Hysterical bar ground: The hospital was founded in 1971 and named after the late Dr. Altigani AlMahi who was the first psychiatrist in Sudan and Africa in general. Before converting it to mental health hospital it was a medical centre seems by the British Mission. Lack of mental health hospital urged the mission to the Sudanese government to establish the mental health hospital in this medical center . The hospital had only three wards at the date of establishment, one for addiction treatment, another for men and the third for women, with the total capacity of 47 beds. In 2001 a ward for neurology was insulated under the supervision of proof. Faroug Yasseen with the capacity of 8 beds for men and 4 beds for women. 4 Chapter Two Literature Review Definition and terminology of conversion disorders: Conversion disorders, is a disorders in which an unexplained loss or alteration of bodily function develops in the presence. The disorders probably occurs more often in women than men and generally begins in adolescence or early adulthood. Patients may have histrionic or dependent personalities and may exhibit remarkable indifference in face of their impairment. Acute conversion symptoms have a good prognosis for recovery, especially if the patient has not other psychiatric disorders(49). Conversion disorders is linked historically to the concept of hysteria, comes from the Latin word (Hysteron) meaning the uterus. It was previously thought the condition occurs only in females due to certain uterus movements, it is a misnomer as it occurs in males and has nothing to do with the uterus. Hysterical reaction represents the attempt never fully conscious and frequently totally unconscious in the part of the patient, to obtain relief from an otherwise intolerable stress, by the exhibition and experience of symptoms of illness (1). Conversion disorders is characterized by deficit affecting the voluntary motor or sensory function. Conversion disorders the term used in the DSM-IV classification system originating from the description by Breuer and Freud (6) of pseudo neurological symptoms 5 resulting from the conversion of unconscious psychological conflict to somatic presentation. Other objectives historically used to describe the same phenomena include "hysterical" or "psychogenic". The seizure subtype of conversion disorders is often referred to as "pseudo seizures" but it is better to choose the term "non-epileptic seizures" because the term "pseudo seizures" may incorrectly imply to the patient, that the symptom is not real. Non-epileptic seizures correctly describe the symptoms without invoking a cause, and patients tend to prefer this term. Beginning treatment with a power struggle over terminology weakness the doctor-patient relationship (19) . Etiology of conversion disorders: 1\ Heredity: Genetic factors may play a role especially in the personality deposition called hysterical personality, characterized by: a) Emotional immaturity with mood swings, fluctuations of temper, out bursts of anger and acting out alternating with warmth and loving feelings. b) Easily suggestible and accordingly takes decisions on an emotional level. c) Inability to sustain long lasting loyalty to maintain interpersonal relationship of any depth. d) Selfishness, inclination to show off, seeking attention and liking to be the centre of attention. 6 e) Dramatic, exaggerating facts, wearing heavy make-up and colorful clothes. f) Histrionic behavior, to him the world is (heaven or hell) at one moment, the patient may be weeping screaming and threatening suicide, disturbing the whole atmosphere and a few hours later, she or he is enjoying herself (himself), laughing and dancing. g) Sexually provocative, although many of them are frigid. 2\ Emotional stress or conflict: Arising from the life situation which differs between patients , may lead to intolerable anxiety which can be converted to physical symptoms (conversion hysteria). E.g. vomiting as symbolic of disgust, coughing as symbolic of protest, headache as symbolic of fear from examination or sexual intercourse, etc… (1) Path physiology: At present treatment is not based on an understanding of the underlying path physiology of conversion disorders. Recent functional neuroimaging studies point to a neurophysiology basis for conversion disorders, triggered by psychological processes. Functional imaging data suggest that neural circuit linking volition, movement and perception are disturbed in conversion disorders (7) although conclusions have been limited by the small numbers of subjects, varying study designs and heterogeneous population. Frontal sub cortical circuits mediate many aspects of behavior (22) . The orbito-frontal cortex serves as a control center, coordinating various regions of the thalamus, amygdala and cortex. 7 Both the orbit-frontal cortex and the anterior cingulated cortex have the emotional and central executive functions and are activated when subjects suppress the competing response suggesting an inhibitory role (3). The anterior cingulated cortex has been implicated in the mediation of consciousness (23). Blood flow to the anterior cingulated cortex is positively correlated with emotional awareness (39) . Preliminary evidence suggests that during conversion reactions, primary perception is intact, but sensory and motor planning is impaired by disruption of the anterior cingulated cortex, orbit-frontal cortex, and limbic brain regions (7). Furthermore, reduced activation of the frontal and sub cortical areas is observed during conversion paralysis (57). A reduced soma tosensory cortex is seen as reduced activation during conversion anesthesia, (42) and reduced activation of visual cortex is noted during ظconversion of blindness (68). Other functional imaging studies of patient with acute conversion paralysis (67) (29) and astasia – abasia (70) also implicated disruption of striato-thalomo-cortex, premotor pathways, with possible pathological inhibition from activation of the anterior cingulate cortex and the orbito-frontal cortex 19). The character of hysteria has many traits in common with that of children, the cortex of the child is insufficiency developed and the sub cortex plays an important part of the child's behavior. In hysteria the cortex is weak, unable to inhibit the sub cortex with the result that 8 there is increased emotionality and so ideas are guided not by reasons but by feelings (1). Conversion disorders symptoms are risk factors: 1\ Motor disturbances: a. Paralysis: in forms of monoplegia, hemiplegia, paraplegia either flaccid or spastic with no true clonus and no Basniski reactions, contractures not uncommon, contrary to organic hemiplegia, proximal weakness is extended instead of the semiflexion, and the gait is extended and not in cirucumduction. b. Aphonia: The patient cannot phonate words but continues to cough as the vocal cords are not affected, he can't utter a single word although he communicates freely and correctly in writing, a point of differentiation from organic aphasia. c. Fits: Those should be differentiated from epileptic fits by the usual sequence of tonic than colonic movements, fits occur in presence of an audience and never occur during sleep, they rarely hurt themselves, absence of incontinence or cyanosis or tongue biting and resistance to interference, attempts to pull their hair, to tear clothes and to scratch and strangle themselves. d. Tics and tremors: Usually coarse in nature and semi-chore form, clonic movements may occur. e. Coma or stupor: The patients appears to be a sleep without breathing difficult and no abnormal signs apart from organic coma, it should be differentiated from catatonic schizophrenia, depression stupors and delirious states. 9 f. Torticollis: Should be differentiated from inflammatory, rheumatic, glandular, spondilosis, etc… All these motor disturbances have a symbolic meaning e.g. Aphonia as she cannot explain her feelings paraplegia as she is disinclined to proceed with her marriage or examination. Torticollis as she does not want to look at her husband, who sleeps beside her. Fits: whenever she faces a difficult examination or to escape from an argument with her husband. 2\ Sensory disturbances: a. Hysterical anesthesia: Not follow anatomical distribution but is frequently total as the patient cannot feel the pin prick as compared with organic anesthesia. b. Hysterical blindness: It has a sudden onset, pupils react to light and the patient avoids objects that would injure him. c. Hysterical pains: The commonest form of expression of the illness, it is bizarre in description and its fluctuation, is related to emotional conflicts. It is frequently miss-diagnosed as rheumatic pains and is usually symbolic of some conflicts in the patient's life. d. Visceral disturbances: All somatic symptoms can be stimulated by hysteria, e.g. vomiting, cough, hiccough, belching, globus hysterics, pseudocyesis, etc… Anorexia Nervosa in its hysterical form is characterized by: a. Refusal of food either by induced vomiting or forced purgation. 10 b. Loss of weight. c. Amenorrhea. The patient is active and energetic in spite of her fragile state, a point of differentiation with Simmons’s and Addison's disease (1). So symptom list of conversion disorders can include amnesia, difficulty swallowing, loss of voice, deafness, double vision, blurred vision, blindness, fainting or loss of consciousness, seizures or convulsions, trouble making, paralysis or muscle weakness, urinary retention or difficulty urinating (49). Diagnosis of conversion disorders and risk factors: Conversion disorders is linked historically to the concept of hysteria, toward the end of the 19th century Pierre Janet conceptualized hysteria as a dissociative disorders and described somatoform aspects of this condition in his traumatized patients (66) . In the beginning of his career, Janet's contemporary Sigmund Freud also considered hysteria as a trauma – based disorders (29) . However, Freud later conceptualized the somatoform symptoms of hysteria as a result of neurotic defense mechanism, and referred to them as conversion symptoms. In DSM II, the conversion and dissociative types of hysterical neurosis were classified as variants of single disorders, in DSM III and its sequence versions, dissociative disorders have been considered as a separate group. On the other hand the latest international classification of disease, the ICD-10, put all manifestations of hysterical neurosis as dissociative disorders; this is in accordance with the findings of modern studies that have evidence 11 for the relationship between somatoform symptoms and dissociation (58, 59, and47) Conversion disorders is unique among DSM – III – R somatoform disorders in that the definition not only describes the diagnostic criteria, but also proposes psychological mechanism as explanation of mechanism termed "secondary gain" which is invoked when unexplained symptoms allow the patient to avoid onerous tasks or undesirable duties. A secondary mechanism "primary gain" is invoked when conversion symptoms appear to resolve an internal conflict created by a feeling, impulse or wish that individual may find frightening or morally unacceptable. So conversion disorders has a good prognosis for recovery, especially if the patient has no other psychiatric disorders (49). Conversion disorders characterized by the presence of deficits affecting the voluntary motor or sensory function, these symptoms suggest neurological or organic causes but are believed to be associated with psychological stressors (DSM IV). Pierre Janet had emphasized the relation between conversion disorders and childhood trauma by the end of 19th century. He viewed dissociation of cognitive, sensory and motor processes as adaptive in the context of an over whelming traumatic experience (34,50) . Unbearable emotional reactions to traumatic experiences would result in an altered state of consciousness. Because Janet considered this alteration in consciousness to be a form of hypnosis, he referred to as "autohypnosis" theory of conversion disorders with assumptions that there is a relation between conversion symptoms and hypnotic susceptibility confirmed by two systematically controlled studies 12 (35,55) , the other assumption is that conversion disorders is associated (50) with childhood traumatization . Despite the fact that this assumption is widely adopted, pseudo seizures from the only type of conversion disorders to which clear evidence with traumatic experiences has been shown (4 ,36). Now there is evidence that there is a relation between the presence of childhood traumatization with conversion disorders. Currently, the emotional neglect (27,48) and physical abuse (43) is strongly emphasized and sometimes found to be more important that sexual abuse, not like until recently all etiology of dissociation in adults has focus primarily on sexual abuse. The main prediction of autohypnosis theory is that there is a relation between childhood traumatization cognitive or somatoform dissociation symptoms that is mediated by a process in which trauma patient uses his or her innate hypnosis capacities to induce "self hypnosis" as a defense mechanism of response to over whelming traumatic events (10, 30) , this prediction implies that persons who are more capable of evoking dissociative experiences under hypnosis might be more likely to develop conversion symptoms in reaction to traumatization (21). Risk factors of childhood traumatization: 1. Parental dysfunction: The expression (parental) refers to biological parents, stepparents and adaptive parent. Parental dysfunction is a conceptualization of emotional neglect, (27,48) referring to the unavailability of parent to recurrent illness, 13 nervousness, depression or use of sedatives and lack of parental affection (27). 2. Physical abuse: Defined as severe parental aggression including recurrent and chronic forms of violence frequently resulting in injuries, such as repeatedly being kicked or hit with a fist or an object (stick or belt), being tied up, or being thrown down the stairs. 3. Sexual abuse: Defined as any pressure to engage in or any forced sexual contact before 16 years ranging from fondling to penetration (27) , notice fondling is not taken in account because it lacks evident clear definition and its relation to adult. Psychopathology lacks evidence. More important is to know about perpetrators (more than one, in different times, sexual activities, force or pressure, frequency, age at onset and duration of sexual abuse. There are studies that show that patients with conversion disorders who reported multiple traumatization show more sever symptom than patients with one type of traumatization (21) , and that patients with conversion disorders reported higher incidence and more sever forms of physical, sexual abuse than patients with affective disorders. Contemporary authors argued that conversion symptoms involve a dissociation of sensory and motor processes "dissociative phenomena" evoked in hypnosis conversion disorders. The dissociative phenomena are characterized by "inhibited explicit" (conscious, voluntary) information processing while implicit or automatic information processing is still intact (11). Patients with conversion blindness, for example typically report no explicit 14 awareness, whereas visual stimuli have frequently been shown to implicitly influence their behavior, dissociation between implicit and explicit information processing is called cognitive dissociation when memory functioning and somatoform dissociation when it affects sensory or motor functioning, as it is in conversion disorders (21). Diagnosis criteria for conversion disorders (6): 1. A loss of, or alteration in, physical functioning suggesting a physical disorders. 2. Psychological factors are judged to be etiologically related to the symptom because a temporal relationship between a psychological stressor that is a parentally related to a psychological conflict or need and initiation or exacerbation of the symptom. 3. The person is not conscious of intentionally producing the symptom. 4. The symptom is not a culturally sanctioned response pattern and can not, after appropriate investigations be explained by a known physical factor. 5. The symptom is not limited to pain or to a disturbance in sexual functioning (49). Diagnostic of psychogenic non epileptic seizures has become easier by video EEG monitoring (12) measurement of serum prolactin(13) selective use of neuropsychological tests other diagnostic methods like seizure like events (25). 15 (14) and various Psychiatric co-morbidity in patients with conversion disorders: Majority of the patients with conversion disorders (89.5%) still has a psychiatric disorders at follow up. The most prevalent were anxiety disorders. Somatoform, affective and dissociative disorders were common as well. At least one psychiatric diagnosis was found in (89.5%) of the patients of conversion disorders, dissociative disorders was seen in 47.4% of conversion disorders patients. They can have dysthymic disorders, major depression, somatization disorders and borderline personality disorders, also childhood emotional and sexual abuse, physical neglect; self mutilate behavior. So co morbid dissociative disorders should alert clinicians for the chronic and complex psychiatric conditions. The predominate of acute conversion symptom in admission should not lead the clinician to over look the underlying psychopathology process among these patient (20). For example therapy for non epileptic seizure must take into account the likelihood that patients with conversion disorders will also meet the criteria for another axis I disorders. Typical co morbid diagnosis include mood disorders post traumatic stress disorders panic disorders, generalized anxiety disorders, dissociative disorders, social or specific phobias and obsessive compulsive disorders (37,60). Axis II pathology with close relatives to psychotic illness are also common. Example of study in patients with non epileptic seizures, depression is the most co morbid diagnosis occurring 100%, also common are anxiety disorders (11 – 80%), dissociative disorders 16 (90%), other somatoform disorders (42 – 93%) and personality disorders (33% - 66%) (42). The strong overlap of non epileptic seizures with dissociative disorders has prompted some authors to propose reclassifying conversion disorders in the dissociative disorders spectrum (43). For proper diagnosis of conversion disorders there is a need of using DSM IV axis I and axis II with psychiatrist specialized in treatment of conversion disorders, trained psychologist neurologist responsible for the somatic screening. A study about childhood trauma in Turkey showed that both somatoform and psycho form dissociation are correlated with reported childhood trauma (51,61) , 46.0% reported childhood physical abuse and 33.0% reported childhood sexual abuse (48), high sexual abuse rates have been found among patients with pseudo seizures and somatization disorders (49) and in conversion disorders patients in general (50). Sexual abuse and dissociation are independently associated with several indicators of mental health disturbance, including taking behavior such as suicidal, self mutilation and sexual aggression (38). In Turkey prevalence of conversion disorders in one month as observed both in psychiatric clinics and general medical settings is quite frequently 27.2% prevalence of conversion symptoms (5) . Patients with conversion disorders have overall psychiatric symptom scores close to those of other psychiatric patients (59) suggesting high psychiatric co morbidity. In a primary health care centre, conversion symptoms were more frequently observed among subjects who had 17 an ICD – 10 diagnoses, depression, generalized anxiety disorders, and neurasthenia were the most prevalent psychiatric disorders (5). In other study in Turkey over a 12 month period (1997) in psychiatric unit of university medical hospital in Sivas, the patients who are diagnosed of conversion disorders 68 patients 48 (70.6%) had pseudo seizures. 9 (13.2%) had paralysis (7 (10.3%) had paresthesia and 2 (2.9%) had been unable to speak(16). Pseudo seizure: is the most frequently seen conversion symptom in Turkey (5) and female patients are usually over presented in studies of conversion disorders from Turkey (64) , Western Europe (22.50) and Northern America (55). In an epidemiological study in Turkey (56) although, there was no difference in average dissociation score between genders, two times as many women than men including among high scores. 18 Management: Guidelines for the management of patients with conversion disorders include: 1. Be certain that the patient had an adequate medical evaluation since many patients have an undiagnosed medical disorders. 2. Review the various explanatory perspectives for factors that might be promoting the development of conversion symptoms. a. Psychiatric illness (especially major depression). b. Personality disorders (especially dependent and histrionic types). c. Behavioral models e.g. sick family members, increase attention from family members supporting the sick role. d. Aspects of the patient's life story, e.g. violent feelings toward an abusive alcoholic father. e. Emphasize the evidence that no serious disease is present, express optimism about the prospect of full recovery. f. Stress that emotional factors may exacerbate such problems. Review the patient's current life and difficulties and consider undertaking course of short time counseling (49). Treatment options of conversion disorders e.g. non epileptic seizures. 1. Address relevant risk factors, e.g. psychiatric co morbid conditions and communication difficulties. 19 2. Psychological intervention (to minimize the perpetuator) factor and recognizing triggering events (17, 24, 32,65). 3. If a patient has substantial cognitive impairment or communication difficulties, treatment is best focus on simple behavioral intervention, physical therapy, reason and helping the patient verbality, distress (56,71). 4. Working with family unit may be necessary when family and socio cultural factors predominate. Family therapy intervention help the patient and family recognize and find issues that may be cause of symptoms, to suppress emotion stress, and to use the therapy with a problem centered system approach (45). 5. Recognition and treatment of comorbid conditions are almost always necessary for symptoms resolution. 6. If patient continues to be symptomatic offer risk factor have been addressed, turn to psychological treatment focusing direct on perpetuating factors using cognitive behavior therapy to address illness believes and denial of stress and modifying the control (46, 45). 7. You can also use psychodynamic psychotherapy to help patients to reform their world viewing empathic interpretations and the development of insight enabling the process of working through past rather than relying on dissociation as a defense (46). 8. Group therapy preferably in conjunction with concurrent individual therapy for psychoeducational concept and provide opportunities for patients to learn from and help each other (41,13) . 20 9. Multidisciplinary inpatient treatment, for patients with severe and prolonged symptoms but such resources are not available for many patients (18). 10. Hypnosis as adjunctive treatment but not essential for treatment (54) . 11. Pharmacotherapy: medications for comorbid and somatic symptoms (28). 12. The most effective is comprehensive approach or treatment program, recognition of risk factor, treatment of comorbid disorders and conditions with a focus on cognitive styles that perpetuate symptoms focus on patient – doctor relationship, which can influence outcomes, limiting the unnecessary testes and medication and procedures. Judicious medication to treat comorbid conditions a lone or in combination with psychotherapist is often needed for sustained recovery. Prognosis and course: Between 50% and 90% of patients with conversion disorders exhibit short term resolution of symptom after reassurance, but as many as 25% of these responders relapse or develop new conversion symptom over time (28). Along duration of symptoms and tremor on non epileptic seizure subtype are associated with a worse prognosis. Among patients with non epileptic seizures even those with symptomatic improvement may remain disabled (28). Diagnoses of personality disorders, previous treatment and along history of illness were associated with a poor diagnosis. 21 Previous Studies: The researcher did not find any previous studies in the research domain , there are some previous studies related to conversion disorder with other variables . study (1) Effectiveness of hypnoses in treatment conversion disorders . Done by Amona Taj El ser (2005). of The objective is to know the effectiveness of hypnoses in treatment of conversion disorders, and explain the relationship between hypnoses response and demographic change of conversion disorders patients, the research design is experimental design . Using tools such as application, primary information (data), personnel interviews (meeting) and conversion disorders measure . sample of study 40 patient divided into 2 groups control group ,experimental group. The data are analized using (ALPH,) K2 test. research results is that there are variations The study in the degrees of conversion disorders measurement , before and after hypnoses that proove the effectiveness of hypnoses in treatment of conversion disorders . Also the study prove that there are no in the hypnoses response according to the sex (male- female) in the age classification (22-28) (29-35) years. And this response can be decreased when the duration of conversion disorders prolonged . And the response is decrease in people who has a high educated level. Study (2) The prevalence of childhood abuse among the patients of conversion disorders . Done by Samia Higazi (2002) . Objectives: 22 1. to investigate the prevalence of child abuse i.e. emotional, physical, and sexual abuse that took place in medium and late childhood (6-12) years among the patient of conversion disorders . 2.To investigate the difference in child abuse among patient of conversion disorders according to sex and caretaker in childhood . The researcher used the descriptive method . The sample of the study include all patients of conversion disorders who visited the psychiatric hospital in Khartoum state during the period of data collection the size of the sample is (50) patient (36) Females (14) males . The tool of data collection is by biographical form designed by researcher ,by the child abuse scale prepared by David Benstien (1995), and the diagnostic criteria of conversion disorders prepared by the American psychiatric diagnostic statistical manual for mental disorders (1994) (DSM VI), as a reference in diagnostic conversion disorders . 1. The data had been manipulated by the computer using the statistical package for social science (SPSS) .the results of the research: 1.there is high prevalence of child abuse and sexual abuse in children( 6 -12)years among patients of conversion disorders. 2. There are differences among patients of conversion disorders according to sex and care taker in childhood . study(3) Dissociation, Childhood interpersonal Trauma, and Family Functioning in Patients with somatization Disorders 23 Richard.J Brown, Ph.D, Clin. Psy. D. Anette Scharge, M.D. Ph.D., and Michael R. Trimble, M.D. The Objectives: 1.to determine the occurrence of various dissociative phenomena in patients with somatization disorders. 2.the occurrence of six different types of childhood interpersonal trauma in these patients, and the nature of these patients, early family environment . Method: Twenty–two patient with somatization disorders and medical comparison subject completed the structured clinical inter-view for DSM- IV dissociative disorders the childhood trauma interview , and the family functioning scale .the type of the study is comparative study . Results: 1.The somatization disorders patients reported significantly higher level of dissociative amnesia than the comparison subjects . 2.The two group reported similar levels of depersonalization,identity alteration. 3.Somatization disorders patients reported significantly greater childhood emotional abuse and more severe form of physical abuse, relative to the comparison subject, 4.chronic emotional abuse being the best predictor of unexplained symptoms. 24 5.childhood sexual abuse, separation / loss , and witnessing violence were equally common in the two group . 6.The somatization disorders group reported significantly more family conflict and less family cohesion. conclusions: 7.only some types of dissociation are more server in patients with somatization disorders ,relative to medical comparison subjects. 8. Many patients with somatic conversion disorders action disorders are raised in an emotionally cold, distant, and unsupportive family environment characterized by chronic emotional and physical abuse. 9. Sexual abuse is not a necessary prerequisite for the disorders. Study(4) Childhood Abuse in Paints with conversion disorders, Karin roleofs, Ph.D. Ger. P.J. Keijsers, Ph.D Kess. A.L Hoogduin, M.D., Ph.D., Gerard W.B. Narining, Ph.D., and Franny C. Moene . Ph.D . November 2002 Objectives: 1.to examine the relationship between conversion disorders and childhood traumatization, and to investigate whether phonetic susceptibility mediates the relation between trauma and conversion symptoms, as suggested by Jane's auto-hypnosis theory of with conversion disorders and 50 conversion disorders. Method and sample size : A total of 54 matched patient comparison patients with an affective disorders were 25 administration the structured measures of cognitive Trauma interview as well as (Dissociative Experiences Scale and somatoform (20 item somatoform dissociation questionnaire) dissociative experience. Results: 1.Patients with conversion disorders reported a higher incidence of physical /sexual abuse, a larger number of different types of physical abuse, sexual abuse of longer duration, and incestuous experiences more often than comparison patients., 2. within the group of patients with conversion disorders, parental dysfunction by the mother – not the father- was associated with higher scores on the dissoicative experiences scale and the somatoform dissociation symptoms, (Structural clinical interview for DSM-IV Axis I disorders) 3.Hypnotic susceptibility proved to partially mediate the relationship between physical abuse and conversion symptoms . 4.there is evidence of a relationship between childhood traumatization and conversion disorders. Study (5) A study of clinical correlations and socio– demographic profile in conversion disorders, Kamala Deka, Pranti K Chaudhyry, Kavery Bora, Pranab Kalita Department of psychiatry, Assam Medical college and Hospital, Dibrugarh , Assam India . Jun 2008 . Objective : 26 to study the clinical presentations and relationship of sociodemographic variables with conversion disorders . Method: for patients admitted to the department of psychiatry, Assam Medical collage and Hospital, Dibrugrh, during November 2004 to August 2005 who fulfilled the inclusion criteria of the study were evaluated for socio – demographic variables and clinical presentation on a semi – structural pro forma . Results : 1. conversion disorders is more common in young adults (57.5%) females,(92.5%) and among student belonging to unclear family of lower socioeconomic status. 2.A majority of the patients had obvious precipitating factor, for which family related (40%) and school– related (30%) problems accounted for the major types. 3.Motor symptoms were the predominant presentation (87.5%) with pseudo seizure being the commonest. Researcher comment : From the previous studies the researcher extract that there is no variations in the effectiveness of hypnosis treatment in patients of conversion disorders according to age groups and sex, the effectiveness of hypnosis treatment is decreased in patents of conversion disorders with higher educational levels, there is increase prevalence of child abuse (6 -12)years among patients of conversion disorders as a predisposing factors with differences in sex and care taken by parents, also there is a significant relationship between child abuse (sexual, physical, emotional, the parental dysfunction by the mother )and the conversion disorders . 27 The conversion disorders are common in young adults, females, students from lower socio-economic status and precipitating factors (school related, family related. 28 Chapter Three Methodology and procedures This chapter explains how this study and carried out on the light of the following headings: Study approach, population materials (data collection method) in addition to the statistical processing used o verify the hypothesis. Study Approach: The approach utilized in this study is the retrospective study design, due to the fact that it is the most appropriate approach for such type of study. since it seeks to correlate various variables with conversion disorders (correlational study). This study is conduct on patients with conversion disorders who are attending Altigani Almahi psychiatric hospital during period (2003-2008) data collection method: The information was gathered using secondary sources (hospitals records) from the archives. Study area: Altijani Almahi hospital located in Omdurman city Khartoum state capital of Sudan, it accommodate 119 beds in causality department and 107 beds in general wards, there are 14 house officer, 17 medical officer, 10 medical registrar and 7 consultants. Patients attending the hospital about 2500- 3000 patients per year. 29 The hospital consists of causality department with causality ward for short stay, out patient and referral department, E.C.T, department, nutrition department and administration department. Study population: Records of out patients attending at the referral clinic in the hospital in the period form 2003- 2008. Sampling: all patients records in the period mentioned were checked. The table(1) indicate the frequency of basic information. The age of patients , gender , education level social economic status, martial status. 30 Table (1): Socio-demographic profile subjects Show the frequency and percentage of the basic information of ( n=100) for the study (sample ) variables. Variables Variants frequency Percentage variable levels 1 2 3 4 5 Age Sex Educational level Marital status Socio-economic classes Less than 12 5 5% 12 – 24 67 67% 25- 36 18 18% 37-48 9 9% Above48 1 1% Male 30 30% Female 70 70% Illiterate 12 12% Primary 31 31% Secondary 36 36% University 21 21% Married 25 25% Un married 75 75% Poor 12 12% (middle) average 88 88% Study Design: Retrospective study design , The retrospective studies investigate aphnomon , situation , problem or issue that has happened in the past they are usually conduct either on the basis of the data available for that period or basis of respondents recall of the situation. (Research methodology Second edition by Rannjit Kumar p.g. 99 (2005). 31 Material and methods: All available records form hospital statistical office and archives. Procedures: 1.The researcher collected the data and information after the approval of the hospital authority from the hospital records and files 2.The researcher arrange the information collected in tables with the variables required for the study and give specific number for every variable. 3. The data is manipulated by the computer applying the statistical package for social sciences (SPSS) using Chi-square test to analyze the data . 4. . The researcher explain the result, make comparison with the hypotheses to obtain the final results . 32 Chapter four Results and Discussion The results from the research are compared with the hypotheses formulated by the researcher hypothesis (1) Conversion disorders is more common among females. Research result of hypotheses (1) As observed from table (2) that there is no significant correlation between gender and symptoms. Table (2) X2: to investigate the relationship between gender and symptoms among the study population. Precipitate Paralysis Seizer A Phonia Body pain Total Gender Male 6 10 8 6 30 Female 14 36 14 6 70 DF Chi-square Asymp. Sig. (2 sided) 1 4.205 0.240 Hypothesis number (2): Conversion disorders is more common in low socio-economic classes: Research result of hypotheses (2) Is that Conversion disorders is more common in low socio economic classes. From table (3) 33 Table (3) X2: to investigate the relationship between socio-economic status and symptoms among the study population. socio-economic status Precipitate poor Paralysis Seizer A Phonia Body pain Total avarage 18 42 21 7 88 2 4 1 5 12 Chi-square DF Asymp. Sig. (2 sided) 11.710 1 0.008 Hypothesis (3): Conversion disorders affect more age group (12 -24)adolescents group Research result: As observed from table (4) is that there is no significant relationship between conversion disorders and age group (12 - 24)adolescents group Table (4) X2: to investigate the relationship between conversion disorders ,age group (12 -24)adolescents group and age as general. Age > 12 12-24 25-36 37-48 > 48 0 4 1 0 13 29 16 9 3 9 3 3 3 4 2 0 1 0 0 0 ChiSquare DF Asymp.Sig 2 sided 9.814 12 0.632 Symptoms Paralysis Seizer A Phonia Body pain Hypothesis (4) Conversion disorders is common among unmarried subjects The Research result: 34 As observed from table (5) is that there is no significant relationship between conversion disorders and marital status. Table (5) X2:investigate the relationship between conversion disorders and marital status among the study population. Precipitate Martial Married Unmarried Chi-square Paralysis Seizer A Phonia Body pain Total 14 37 16 8 75 6 9 6 4 25 1.496 DF Asymp. Sig. (2 sided) 3 0.683 By referring to result in table (5) above it seen that there is no significant difference between the married and unmarried in conversion disorders. Hypothesis (5): Conversion disorders are common among low-education level classes. The Research result : As observed from table (6) is that there is no significant relationship between educational level and conversion disorders according to the result of chi-square test. Table (6) X2: to investigate the relationship between conversion disorders and educational level among the study population. Precipitate Educate Illiterate Primary Secondary University Paralysis Seizer A Phonia Body pain Total 3 5 2 2 12 7 15 6 3 31 6 17 9 4 36 4 9 5 3 21 35 Chisquare DF Asymp . Sig (2 sided) 1.511 9 0.997 Chapter Five Discussion This chapter deals with the discussion of the results after being analyzed statistically by chi–square test. Since the hypothesis discussed in light of previous studies. In the first hypothesis, which postulated that conversion disorders is more common among females due to the following:1. conversion disorders appears to be more frequent in women than in men , with reported ratios varying from 2:1 to 10:1 , ratio – among children . 2. in men , there is an association between conversion disorders and anti social personality disorders. 3. conversion disorders in men is after seen in the context of industrial accidents or military . Some psychiatrist think that the high female to male ratio. in this disorders reflects the cultural pressures on women in north American society and the social ( permission) given to women to be physically weak or sickly. However the gender ratio is closer to 1:1 may reflect the greater vulnerability of females to abuse . Cultural influences appear to affect the gender ratios as will as there frequency in a specific population. Some cultures (( for example) Greek and Puerto Rican ) report higher rates of somatiza tion disorders among men than is the case 36 for the united states , and that show the finding in this study although there are differences in culture ( religious, traditions and costumes ) there are certain believes like express of feelings which is accepted in our culture to female rather than male . In the second hypothesis which stated that conversion disorders is more common in low socio-economic status . It be observed that there is significant correlation coefficient between the economic status and conversion disorders in study population from the result of (3) . This argument supported by studies that conversion disorders is a major reason for visits to primary care practitioner .one study of health care utilization estimate that 25-72% of office visits to primary care doctors. A study estimates that at least 10% of all medical treatment and diagnostic services are ordered for patients with no evidence of organic disease . Conversion disorders carries a high economic price tag . Patients who convert there emotional problems into physical symptoms spend nine times as much for health care as people who do not somatize and 82% of adults with conversion disorders stop working because of their symptoms . the annual bill or conversion Disorders in the in the united states comes to $20 billion , not counting absentceism from work and disability payment. Hypothesis three claimed that adolescent are more affected with conversion disorders . 37 The incidence and prevalence of conversion disorders are unclear it may be seen at any stage of life. it is fairly common in children but not most common in adolescent and young adults , rarely before age of 10 years or after age of 35 years , but onset as late as the 9th decade of life has been reported when an apparent conversion disorders. First develops in middle or old age, the probability of an occult neurological or other general medical Conditions is high according to DSM4 conversion disorders was classified as a somatoform disease. The somatoform disorders are difficult to recognize and treat because patients often has long histories of medical or surgical treatment with several different doctors . Somatization disorders is consider to be a chronic disturbance that tends to persist through out the patients life may be that why we did not found any significant correlation coefficient between adolescent and conversion disorders among study population . Hypotheses four which states that conversion disorders common among unmarried subjects . The researcher hypothesis that because she think that the married subjects are more happy and stable in their life because they have their own family, children , security and has their emotional live , but the result came negatively may be that is related to some causes, un married in our culture have a support from the family members, solve their problems and this is our culture which give psychological and social support . 38 Un married women are busy with their work friends home, shopping that minimize ,the stresses also the personal relationship. Also the man have also his friends spend time with them. In the adolescent, and this period of human life, which is characterized by gradual development to words physical, sexual, intellectual and psychological maturity, the psychological and social development of the adolescent is influenced by the social and family environment with all its contents (culture, traditions and customs, Norms) which direct the adolescent attitudes and influence his adaptation with himself and with the surrenders. One of the most important feature of psychological development in this period is the tendency of the adolescence to attain an emotional independence from the family, characterized by irritation and anger . This psychological changes are attributed to the feeling of him that he is not longer a child . In addition he may be under many psychological conflicts are as a result of these changes. In the secondary education the student may face many stresses, because of the conflict between his need and his family needs. Hypothesis five postulated that conversion disorders is common among low – educational level classes . The researcher suggested that education level has a role in conversion disorders because the low educated people has ability to suggestion and this is a precipitating factors and the hysterical 39 personality characterized by easily suggestibility and accordingly takes d decisions on an emotional level . There is no significant correlation coefficient between educational level and conversion disorders. As we see in table (6) Illiterate showed (12%) primary (31%) secondary (63%) university (21%) . That the symptoms should cause impairment in social, occupational, educational, or other important area of functioning. Table (7) Patients attending the hospital during 2007 The total number of patients is (1894) Kind of illness SZP Patients (No) ( %) 712 38% Depression 296 5.8% Mania 159 8.5% Bipolar 97 5.2% Psy. Shock. 80 4.3% Toxic Psychosis 108 5.8% Psychological disturbances 283 5.1% Alcohol addiction 51 2.7% Epilepsy 23 1.2% Purple psychosis 15 0.8% Psychosis 7 0.4% Conversion 12 0.6% Dementia 19 1.1% Mental retardation 6 0.3% Anxiety 4 0.2% 40 From the statistical office in Al Tajani Al Mahi Psychiatric hospital . 41 Chapter six Conclusion , Recommendation , References and Appendix Conclusion : 1) There is no significant relationship between gender (male, female) and symptoms of conversion disorders 2) There is significant relationship between socio- economic status and symptoms of conversion disorders 3) There is no significant relationship between conversion disorders and adolescent as age group . 4) There is no significant relationship between conversion disorders and martial status . 5) Their is no significant relationship between coefficient between educational level and conversion disorders . 42 Recommendation : 1) To improve the socio-economic status of population to minimize the predisposing factors leading to conversion disorders symptoms. 2) To make more researches in the same topic to cover other psychiatric hospitals and other psychiatric health center . 43 References: 1. 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