Download malingering and factitious disorder

CONVERSION
DISORDER
PRESENTED BYMrs. Shalini Chhabra Sr. Lecturer
Department of Psychology
D.A.V. College for Girls
Yamuna Nagar
Meaning and Definition of
Conversion Disorder:
A conversion
reaction is a process whereby an
unconscious conflict is transformed into a
body symptom which reduces tension and
anxiety by expressing conflict
symbolically.
According to DSM IV (1994):
“Conversion disorder involves
unexplained symptoms or deficits
affecting voluntary motor or sensory
function that suggest a neurological or
other general medical condition.
Psychological factors are judged to be
associated with the symptoms or
deficits.”
Conversion Disorder is:
1. Considered to be the most complex and
difficult to understand mental
disorder.
2. Important type of somatoform
disorder.
3. ‘Soma’ means ‘Body’. Individuals
suffering from the disorders are
continuously preoccupied with their
state of health, with presumed
disorder or diseases of bodily organs.
4.The most common feature of all
Somatoform disorders is the presence
of physical symptoms that suggest a
general medical condition but for which
no organic basis can be found that
satisfactorily explains the symptoms.
5. Somatoform disorders are:
AXIS-I clinical disorders- according to
DSM IV.
6.In conversion disorder, symptoms of
some physical malfunction or loss of
control appear without any underlying
organic pathology.
7.These symptoms resemble neurological
disorders of one kind or another and are
thus described as
“Pseudo neurological” in nature.
Earlier View:
 Conversion is originally known as
“ HYSTERIA.” The term ‘hysteria’ was
derived from the Greek word meaning
‘Uterus.’
 Hippo crates and many other ancient
Greeks were of the view that ‘Hysteria’ is
restricted to women.
According to them, the main cause was
the sexual difficulties, particularly the
wandering of a frustrated womb to
various parts of the body because of
sexual desires and a yearning for
children. Thus the uterus might lodge in
the throat and cause chocking sensations,
or in the spleen, causing Temper
Tantrums.
 Hippocrates considered marriage the
best remedy for Hysteria.
Later on, Freud used the term
“Conversion Hysteria” for these
disorders.
Freud believed that the bodily symptoms
were an expression of repressed sexual
energy-i.e., the unconscious conflict a
person felt about his or her sexual
desires that was converted into a bodily
disturbance.
 As this was not done consciously, the
person was not aware of the origin or
meaning of the physical symptoms.
Contemporary View:
 Though still called a ‘Conversion
Disorder’, in contemporary
Psychopathology, the physical symptoms
are now usually seen as serving the
obvious function of providing a reasonable
excuse, enabling an individual to escape or
avoid an intolerably stressful situation
without having to take responsibility for
doing so.
The term ‘Secondary Gain’ which
originally referred to advantages of the
symptoms beyond the ‘Primary Gain’ of
neutralizing intrapsychic conflict, has
also been retained.
Generally, it is used to refer to any
circumstance, such as attention from the
loved ones or financial compensation, that
would tend to reinforce the maintenance
of disability.
Decreasing Incidence:
Conversion Disorder was once common in
civilian and especially in military life.
This disorder was the most frequently
diagnosed psychiatric syndrome among
soldiers in World War I and II.
(Conversion symptoms- such as paralysis
of the legs- enabled a soldier to avoid an
anxiety arousing combat situation without
being labeled as coward or being
subjected to court martial).
Today Conversion Disorder constitutes
only 1 to 3 percent of all disorders
referred for mental health treatment.
The decreasing incidence of this
disorder seems to be closely related to
our growing understanding about medical
and psychological disorders.
Conversion Disorder apparently loses its
defensive function if it can be readily
shown to lack an organic basis.
As a result, present cases of Conversion
Disorder show symptoms of strange
diseases that are harder to diagnose,
such as convulsive seizures or some
malfunction of internal organs.
Moreover, these symptoms are not so
obviously and directly related to the
nature of the problem with which the
person is attempting to cope.
Specific culture, age and
gender features:
Conversion Disorder has been reported
to be more common in-rural populations,
individuals of lower socio-economic
status, and in individuals who are less
knowledgeable about medical and
psychological concepts.
Higher rates are reported in developing
nations and regions, with the incidence
generally declining with increasing
development.
In children under 10 years, symptoms
are usually limited to gait problems or
seizures.
More common in women than in men,
ratio varying from 2:1 to 10:1.
In women, symptoms are much more
common on left than on the right side of
the body.
In men, an association with Antisocial
Personality Disorder is evident.
Familial Patterns:
Conversion Symptoms are frequent in
relatives of individuals with Conversion
Disorder.
More common in Monozygotic rather
than Dizygotic twin pairs.
Course:
The onset of Conversion disorder is
generally from late childhood to early
adulthood, rarely before age 10 years or
after age 35 years.
The onset of Conversion Disorder is
generally acute, but gradually increasing
symptomatology may also occur.
Typically, individual conversion symptoms
are of short duration. Symptoms will
remit within 2 weeks in most cases.
Recurrence within 1 year in most cases is
common.
Factors that are associated with good
prognosis include acute onset, presence
of clearly identifiable stress at the time
of onset, a short interval between onset
and the institution of treatment, and
above average intelligence.
SYMPTOMS
SENSORY SYMPTOMS
MOTOR SYMPTOMS
VISCERAL SYMPTOMS
TYPES OF SENSORY SYMPTOMS
ANESTHESIA-Loss of sensitivity
HYPESTHESIA-Partial loss of sensitivity
HYPERESTHESIA-Excessive sensitivity
ANALGESIA-Loss of sensitivity to pain
PARESTHESIA-Exceptional sensations e.g., heat
Some examples of sensory
symptoms:
Visual Symptoms as reported by
Ironside et al., (1945) in their classic
study on airmen in World War II.
1. Blurred vision
2. Night blindness
3. Double vision
4. Photophobia-extreme sensitivity to light
5.A combination of intermittent visual
failure and amnesia.
6.Deficient stereopsis- the tendency to
look past an object during attempts to
focus on it.
7.Restriction in the visual field.
8.Intermittent loss in vision in one eye
9.Colour blindness
10.Jumping of print during attempts to
read.
11.Failing day vision.
Important Observation in the
Study:
Symptoms of each airman were closely
related to his performance duties. E.g.,
night fliers mostly showed night
blindness and day fliers mostly showed
failing day vision.
MOTOR SYMPTOMS
PARALYSIS CONVERSION REACTION
TREMORS
TICS
ASTASIA- ABASIA
APHONIA
MUTISM
Examples of motor symptoms:
1.Paralysis Conversion Reactions:
These reactions are usually confirmed to
a single limb such as an arm or a leg, and
the loss of function is usually selective
e.g., as in ‘Writer’s Cramp’.
2.Tremors(muscular shaking) and
Tics(localized muscular twitches):
Symptoms include contractures, which
usually involve flexing of the fingers and
toes, or rigidity of the larger joints, such
as the elbows and knees.
3.Astasia-Abasia:
This is a type of walking disturbance in
which an individual can usually control leg
movements when sitting or lying down,
but can hardly stand and has disorganized
walk, with both legs wobbling about in
every direction.
4.Aphonia:
This is a very common speech related
conversion disturbance, in which an
individual can talk only in whisper, but can
usually cough in a normal manner. This
usually occurs after some emotional
shock.
5.Mutism:
In mutism an individual is unable to speak.
These types of conversion reactions are
relatively rare. Occasionally, symptoms
may involve convulsions, similar to those
in epilepsy. People with such symptoms,
however, show few of the usual
characteristics of true epilepsy. They
rarely,if ever, injures themselves in falls,
their pupillary reflex to light remains
unaffected; they are able to control
excretory functions; and they rarely have
attacks when others are not present.
VISCERAL SYMPTOMS
LUMP IN THE THROAT AND CHOKING SENSATION
NAUSEA AND VOMITING
DIFFICULTY IN BREATHING
HICCOUGHING AND SNEEZING
COUGHING SPELLS
COLD AND CLAMMY EXTREMITIES
BELCHING
GREAT DEGREE OF SIMULATION OF ACUTE SYMPTOMS
Examples of organic symptoms
Pseudo attack of
Acute Appendicitis
Conversion Reactions of
Malaria and Tuberculosis
Pseudo
Pregnancy
Diagnosis in Conversion
Disorder:
Several criteria are commonly used for
distinguishing between conversion
disorders and true organic disturbances:
A certain unconcern(“la belle
indifference”), in which the patient
describes what is wrong in a rather
matter-of-fact way, with little of the
anxiety and fear that would be expected
in a person with a paralyzed arm or loss
of sight.
The frequent failure of the dysfunction
to conform clearly to the symptoms of
the particular disease or disorder
simulated.
The selective nature of the dysfunction.
Under hypnosis or narcosis( a sleep like
state induced by drugs) the symptoms
can usually be removed, shifted, or
reinduced at the suggestion of the
therapist.
Distinguishing Conversion from
Malingering/ Factitious
Disorder:
Sometimes, of course, persons do
deliberately and consciously feign
disability or illness. For these instances,
the DSM distinguishes between
malingering and factitious disorder on the
basis of the feigning person’s apparent
goals such as an award of money or
avoidance of an unwanted duty or
obligation, in factitious disorder, the
person’s goal is the more general one of
maintaining such personal benefits as the
“sick role” may provide, including the
attention & concern of medical personnel.
Diagnostic Criteria for
Conversion Disorder (DSM IV):
One or more symptoms or deficits
affecting voluntary motor or sensory
function that suggests a neurological or
other general medical condition.
Psychological factors are judged to be
associated with the symptom or deficit
because the initiation of the symptom or
deficit is preceded by conflicts or other
stressors.
The symptom or deficit is not
intentionally produced.
The symptom or deficit cannot, after
appropriate investigation, be fully
explained by a general medical condition,
or by the direct effects of the
substance, or as a culturally sanctioned
behaviour or experience.
The symptom or deficit causes clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning or warrants medical
evaluation.
The symptom or deficit is not limited to
pain or sexual dysfunction, and is not
better accounted for by another mental
disorder.
Precipitating Circumstances:
1.The individual experiences a desire to
escape from some unpleasant situation.
2.He may be having a wish to be sick in
order to avoid the situation.
3.Finally under additional and continued
stress; begins to show appearance of
symptoms of some physical ailment.
4.The individual typically sees no
relations between the symptoms and the
stress situation.
5.Particular symptoms are usually of a
previous illness, or are copied from other
sources, such as, symptoms observed in
relatives, or seen on television, or read
about in magazines.
6.Sometimes, Conversion Disorders seem
to stem from feeling of guilt and the
necessity for self punishment.
7.Once the response is learned, it is
maintained because it is repeatedly
reinforced- both by anxiety reduction or
by whatever gained in terms of sympathy
and support that result from being
disabled.
Etiology:
Psychoanalytic Theory:
Breuer and Freud(1895) proposed that a
Conversion Disorder is caused by an
experience that has created great
emotional arousal.The affect, however, is
not expressed, and the memory of the
event is cut off from the conscious
experience.
They proposed two explanations why the
affect is not expressed:
1.The experience may have been so
distressing that the person could not
allow it to enter consciousness and is,
therefore, repressed it. OR
2.The experience may have occurred
while the person was in an abnormal
psychological state such as semi-hypnosis.
In both situations, the specific
Conversion Symptoms are casually related
to the traumatic event that preceded
them.
Later, he hypothesized that conversion
disorders are rooted in an early,
unresolved “Electra Complex.”
Thus the primary gain from the
Conversion Disorder is the avoidance of
previously repressed “Id” impulses.
Behavioural theory:
Behavioural account of the development
of Conversion Disorders was proposed by
Ullmann & Krasner(1975).
According to them a person deliberately
adopts conversion symptoms to gain some
end.
The person attempts to behave
according to his or her own conception of
how a person with a disease affecting the
motor or sensory abilities would act.
This theory specify two conditions that
increase the likelihood of such behaviour.
The person must have some experience
with the role to be adopted.
The enactment of the role must be
rewarded.
But literature does not support that the
conversion symptoms are a result of
deliberate, conscious effort.
Socio-culture theory:
Socio- culture theories are based on the
supposed decrease in Conversion
Disorders over the last century.
The decline is attributed to a more open
attitude towards sexual desires.
Decline is also attributed to the greater
psychological & medical sophistication
which is more tolerant of anxiety than it
is of dysfunctions that do not make
physiological sense.
Many studies have also supported the
theory likeConversion symptoms are found to be
more common among people of low
socioeconomic status, people having less
education level, and people having rural
background.
Symptoms are found to be more common
among people of underdeveloped
countries.
Symptoms are found to be more common
among conservative societies where frank
expression of emotional distress is
considered unacceptable.
Biological factors:
Genetic factors have been proposed, but
research does not support the theory.
Physiological factors that seem to have
clear relation with the development of
conversion disorder-
Conversion symptoms are more likely to
occur on the left side of the body than
the right side.
The majority of conversion symptoms,
then, may be related to the functioning
of right hemisphere of the brain.
Disconnection of two brain hemispheres
surgically has shown that the right brain
hemisphere can separately generate
emotions, particularly unpleasant ones,
more than does the left hemisphere and
hence responsible for conversion
disorder.
Conversion symptoms thus can be
neuro-physiologically linked to emotional
arousal.
Right and left hemisphere of the brain
is connected by corpus callosum. The left
hemisphere has the verbal capacity to
describe and explain emotions and
thereby to gain awareness about them
but this capacity is lacking in right
hemisphere and thus responsible for
conversion disorder.
In Conversion Disorder, left
hemisphere somehow blocks impulses
carrying painful emotional content from
the right hemisphere.
Thus the person with conversion
disorder makes no connection between it
and his troubling circumstances or his
emotional needs.
Treatment:
As most of the persons with Conversion
disorder define their symptoms in
physical terms, they go more often to
physicians than to mental health
professionals.
The ‘Talking Cure’ or ‘Free Association’
developed by Psychoanalysts is based on
the assumption that a massive repression
forces psychic energy to be converted
into conversion symptoms, therefore,
Catharsis should be done. Which however
have not been found to be very effective.
Many Behavioural therapeutic techniques
are in use and found to be effective to
some extend such as-
Systematic Desensitization. Family
Therapy. Assertion Training.
Social Skill Training. In Vivo Exposure.
Operant Training Feedback.
In many instances the best treatment
comes out to be no treatment at all but,
rather the provision of support,
reassurance and non threatening
explanation of the causal factors.
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