Introduction

The phenomenology and treatment of conversion symptoms (hysteria) extend back at least 4,000 years (Veith 1965). In this chapter, I focus on treatment of conversion disorder; however, because principles of diagnosis and treatment must be based on knowledge of the underlying basis of the phenomenon, I briefly review the etiology of the disorder before describing a variety of therapeutic interventions. Several syndromes traditionally associated with hysteria are now subsumed in the diagnostic category somatoform disorder not otherwise specified (NOS). Treatment approaches for two of these syndromes, pseudocyesis and mass psychogenic illness, are also described in this chapter.

Conversion Disorder

Diagnosis

The DSM-IV (American Psychiatric Association 1994) diagnostic criteria for conversion disorder are listed in Table 59-1. In brief, they require that a symptom simulate a neurological or general medical condition that involves voluntary musculature or sensory organs, excluding pain and sexual function. The symptom should cause significant distress or impairment in social, occupational, or other important areas of functioning and not be a culturally sanctioned behavior.

The initiation of the symptom should be judged to be associated with psychological conflicts or stressors and not be intentionally produced or feigned. Thus, unlike the criteria for most other psychiatric disorders, the diagnosis of conversion disorder (and several other somatizing syndromes) requires a subjective judgment by the clinician as to whether a psychologically significant stressor for the symptom was present and whether the patient has conscious control of the symptom. Because no clinician is a mind reader, these important diagnostic determinations must rest on inferred evidence (e.g., Is the symptom present only when the patient believes that someone is observing?). In fact, the somatizing disorders (which include malingering, factitious disorders, and disability syndromes in addition to the somatoform disorders) often represent various ranges of phenomena, such as degree of conscious awareness, secondary gain (see “Secondary Gain” subsection later in this chapter), and response to precipitating stressors. In the clinical setting, the diagnostic boundaries are blurred, and symptomatic presentations are fluid over time (Ford 1992).

The differential diagnosis must include all of the aforementioned conditions as well as the DSM-IV category psychological factor affecting medical condition. With respect to treatment (but not necessarily legal issues), the exact diagnosis of conversion disorder is usually not only impossible but also, fortunately, not necessary. The treatment strategies and interventions presented later in this chapter are highly specific to the individual rather than to a diagnostic category.

Characteristics Associated With Conversion

Several characteristics traditionally have been associated with the diagnosis of hysteria. Many of these have persisted into current usage and are described in textbooks, despite having been proven of little value. Factors judged to be useful in the diagnosis of conversion disorder are summarized in Table 59-2.

Prevalence Conversion is often said to be a historical disorder that is little seen in modern times or in Western countries. However, it appears that as the general public becomes more medically sophisticated, there is an increased tendency to see simulations of poorly defined illnesses (e.g., chronic fatigue syndrome, hypoglycemia, amalgamism) rather than the cruder simulation of neurological diseases that was more common at the turn of the 20th century (Ford 1997b; Stefanis et al. 1976), although limited data support this hypothesis. Attempts to determine changes in the incidence of conversion are further complicated by the changes in diagnostic criteria. Thus, definitive statements cannot be made as to whether conversion is more or less prevalent now than in the past. Certainly, consultation-liaison psychiatrists continue to see a significant number of conversion disorder patients (Ford 1995; Ford and Parker 1991). Conversion disorder should not be ruled out on the basis that it is a rare or archaic disorder.

Gender Conversion disorders (e.g., hysteria) historically have been associated with women. Most studies in adults, including contemporary series, continue to report a predominance of the disorder in women. However, conversion does occur in men, and the apparent prevalence in women may reflect a diagnostic bias. In one tertiary care setting, approximately the same number of men as women had conversion disorder (Crimlisk et al. 1998). Certain settings, such as the military or disability evaluations, may include a majority of men (Allodi 1974; Carden and Schramel 1966; Weinstein et al. 1969). Conversion in children is equally divided among boys and girls (Maloney 1980).

Age Conversion symptoms occur in all age ranges, from young children to elderly adults (Shulman and Silver 1985; Woodbury et al. 1992; Wyllie et al. 1999). In some pediatric psychiatric consultation services, conversion disorder is one of the most frequently diagnosed conditions (Maloney 1980; Srinath et al. 1993).

Personality disorder In contrast to the once popular view that conversion occurs primarily in histrionic (i.e., hysterical) personalities, it is, in fact, at least as common in those with dependent personality disorders. Furthermore, many patients with conversion show no evidence of a personality disorder (Merskey and Trimble 1979; Stephens and Kamp 1962; Ziegler et al. 1960).

La belle indifference An individual’s lack of anxiety or other emotional response to a symptom has long been a hallowed diagnostic marker of conversion. However, in careful studies of conversion, la belle indifference is infrequently found and inconsistently reported. Furthermore, many stoic patients with genuine physical disease may incorrectly appear to be unconcerned about their physical status (Raskin et al. 1966; Stephens and Kamp 1962).

Symbolism Although symbolism is a feature of psychoanalytic views of conversion, it is infrequently identified in conversion patients (Lewis and Berman 1965). There is also the risk that a patient or physician may incorrectly assign a secondary symbolic meaning to a symptom of either conversion or physical disease.

Identified stressor Stress as an identified precipitant of conversion presents the possibility of circular logic because stress is one of the DSM-IV diagnostic criteria for the disorder. Yet stress or psychological conflict is a very frequent finding in conversion. In fact, when conversion appears to be present (e.g., pseudoseizures diagnosed by simultaneous videotaped behavior and electroencephalogram tracings), one should search for a hidden stressor (e.g., sexual abuse in an adolescent).

Secondary gain Secondary gains are extraneous benefits (e.g., increased attention from others) that accrue to a person through occupancy of the sick role. The role of a secondary gain as the cause or reinforcer of conversion symptoms cannot be dismissed. Raskin et al. (1966) found that it was present in most conversion patients. However, the use of secondary gain as a sole diagnostic criterion must be discouraged. Many individuals with physical disorders, including life-threatening diseases, may have significant secondary gains.

Model for the symptom For a person to simulate a disease, either consciously or unconsciously, he or she must have some idea as to the nature of the disease. Many patients with conversion symptoms have a model for their symptom: either an illness that they have experienced or their observation of someone they have known with the symptom (Raskin et al. 1966).

Prior episodes of somatization Many patients with conversion symptoms have had prior episodes of unexplained medical symptoms. Such a history increases the likelihood that the current illness episode also represents somatization (Folks et al. 1984; Lazare 1981).

Nonphysiological symptoms The presence of symptoms that cannot be physiologically explained or that seem to fly in the face of all that is known about neurological function would seem to be a reasonable criterion for diagnosis. Weintraub (1983) detailed several such symptoms. Merskey (1986) took a somewhat more cautionary stance in stating that, as medical research progresses, investigators can often provide etiological explanations for symptoms previously regarded as hysterical.

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Charles V. Ford, M.D.
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