A study of clinical characteristics and psychosocial stressors in patients with conversion disorder.
Dr.Waleed Azeez Al-Ameedy
Psychiatrist/college of medicine /Babylon university
wam.psych@yahoo.com
Dr.Maythem Al-Yasiry
Psychiatrist/college of medicine /Babylon university
Dr.Zeid Al-Yasiry
Neurologist / college of medicine /Babylon university

Abstract
Background :Conversion disorder is the term used in the Diagnostic and Statistical Manual of Mental disorders-Fourth edition classification system (DSM-IV). It was coined by Sigmund Freud.
Objectives : To study and stratify the clinical presentation and psychosocial stressors of patients with conversion disorder.
Method : The sample is composed of 182 patients (52 males and 130 females) referred from emergency department to psychiatry outpatient clinic. DSM-IV criteria was used to diagnose conversion disorder. The Social Readjustment Rating Scale by Holmes and Rahe which ranks the effects of life events was used in our study.
Results : (70.3%) of the patients presented with psychogenic non epileptic seizures. Of the referred cases, 76.9% have had previous history of the same condition and 31.9% had previous referral to psychiatrist. There was significant association between score interpretation of the Social Readjustment Rating Scale by Holmes and Rahe and age, gender, occupation, marital status and previous admission for the same condition.
Conclusion : Episodes of conversion disorders are triggered by psychosocial stressors the severity of which does not seem to correlate with the risk of relapse. The highest incidence of conversion episodes were detected in married, unemployed young females with lower levels of education. The prognosis of those patients improves with early identification and proper psychiatric assessment and management.
Key words : conversion disorder , psychosocial stressors , pseudoseizure.








دراسة الخصائص السريرية والصدمات النفسية والاجتماعية عند المرضى المصابين باضطراب التحويل.
الخلاصة
المقدمة : اضطراب التحويل هو مصطلح استخدم من قبل الدليل التشخيصي والاحصائي الرابع للاضطرابات العقلية . وقام سيغموند فرويد بتسمية هذا المرض باضطراب التحويل .
الأهداف : لدراسة الاعراض السريرية والاحداث النفسية و الاجتماعية لمرضى اضطراب التحويل.
الطريقة : العينة مكونة من 182 مريض ( 52 ذكور و 130 اناث) وتم احالتهم من قسم الطوارئ الى استشارية الطب النفسي. استخدم الدليل التشخيصي والاحصائي الرابع للأمراض العقلية لغرض تشخيص اضطراب التحويل. مقياس التعديل الاجتماعي لهولمز وراه الذي يصنف احداث الحياة وتأثيراتها استخدم في هذه الدراسة.
النتائج: 70.3% من المرضى يعانون من نوبات سقوط غير صرعية نفسية المنشأ (الصرع الكاذب). 76.9% , 31.9% من الحالات كان عندهم تاريخ سابق لنفس الحالة و مراجعة سابقة للطبيب النفساني على التوالي.
كانت هناك علاقة هامة بين تفسير النتائج حسب مقياس (هولمز و راه ) وعمر المرضى , الجنس , العمل , الحالة الزوجية والتاريخ السابق لنفس الاعراض.
الاستنتاج: تعتبر الضغوطات النفسية والاجتماعية المسبب الرئيس لاضطراب التحويل , وشدة هذه الضغوطات لا تبدوا ان لها علاقة بمخاطر تكرار نوبات اضطراب التحويل مستقبلا. اعلى نسبة حدوث لنوبات التحويل كانت عند الاناث , المتزوجات , بدون عمل , ومستوى تعليمي منخفض. التشخيص المبكر والتقييم والعلاج النفسي الصحيح يساهم في التحسن السريع لمرضى اضطراب التحويل.
الكلمات المفتاحية : اضطراب التحويل , الصدمات النفسية والاجتماعية , الصرع الكاذب












Introduction
Conversion disorder is the term used in the Diagnostic and Statistical Manual of Mental disorders-Fourth edition classification system (DSM-IV) and it was coined by Sigmund Freud, who created a theory of conversion of the unconscious psychological conflict to somatic representation and was called Hysteria [1].
Until the seventeenth century, the term hysteria was used and it was thought to result from abnormalities of function or position of the uterus. Later, the idea became accepted that hysteria is a disorder of the brain [2]. Conversion disorder is classified as a somatoform disorder (DSM-IV) and is used to denote a group of neurological symptoms that cannot be explained in terms of known mechanisms of pathology and in which there has been a significant psychological stressor. In contrast, International Classification of Diseases (ICD-10) has classified conversion symptoms as dissociative disorders (e.g. dissociative motor disorder). According to DSM–IV, the presentation of conversion disorder can be divided into main four types:
1- Motor symptoms or deficit: this subtype includes such symptoms as paralysis, ataxia, tremor and difficulty swallowing or lump in throat.
2- Sensory symptom or deficit: this subtype includes such symptoms as numbness, double vision, blindness and deafness.
3- Pseudoseizure (psychogenic non epileptic seizures).
4- Mixed presentation.
The patterns of defects do not usually conform to specific anatomical pathways, and symptoms may fluctuate and intensify when patients are aware that medical staffs are observing them [3].
Research about conversion disorder often suggests that its prevalence is relatively high. Engl (1983) estimated that 25% of patients admitted to general medical hospitals had conversion symptoms at some time in their lives [4].
There seems to be limited understanding of the mechanism by which psychological stress can convert into physical symptoms. Conversion disorder is attributed to conflicts or recent stressors. The relation between stress and illness ( e.g. conversion disorder ) has been shown by Holmes and Rahe whose Social Readjustment Rating Scale can be used to evaluate the patient`s stress[5]. The conversion of emotional arousal to physical symptoms is termed the primary gain while secondary gain refers to the external benefits that may be derived as a result of having symptoms. The somatic symptomatology of conversion disorder lessens the anxiety and gives rise to la belle indifference, where a patient seems surprisingly careless about their physical complaints.
Acute conversion symptoms may undergo spontaneous resolution following explanation and suggestion. Some patients respond to active rehabilitation. Those with chronic conversion symptoms may need admission to hospital and may undergo psychiatric assessment to reveal underlying depression or even previously hidden psychosis[6] [7].
It is essential to provide a cognitive framework for management through the explanation to patients that neurological disturbances can result from loss of conscious control over the affected function.




Aim of the Study:
To cast a light on, and stratify the clinical presentation and psychosocial correlates of patients with conversion disorder in a local Iraqi community.
Patients and Method:
Study design/Study Location: This is a hospital based cross-sectional study that was carried out in Marjan Teaching Hospital during the period 8th of September 2014 to 15th of February 2015. The sample is composed of 182 patients (52 males and 130 females) referred from emergency department to psychiatry outpatient clinic ( all are suspected cases of conversion disorder). Informed consent was obtained from each patient before data was collected. Inclusion criteria include all patients diagnosed with conversion disorder ( by psychiatrist in the outpatient clinic and according to DSM IV criteria ) , in addition to willingness and ability to participate in the study , while patients who refuse to be included in the study were excluded.
Tools of the study: The first part of the questionnaire includes demographic information (name, age, gender, marital status, education level and employment). Clinical presentation of the patients, history of previous admission and the previous referral to psychiatrist also reported in the present study. DSM-IV criteria were used to diagnose conversion disorder. The Social Readjustment Rating Scale by Holmes and Rahe which rank the effects of life events was used in our study. Score ? 150 may indicate high chance of becoming ill in the near future while a score < 150 indicates low to moderate chance of becoming ill in the near future.
Data Analysis: Statistical analysis was carried out using SPSS version 17. Categorical variables were presented as frequencies and percentages. Pearson’s chi square (X2) test and fisher exact test were used to find the association between the categorical variables. A p-value of ? 0.05 was considered as significant.

RESULTS
Table 1 shows the distribution of patients according to socio-demographic characteristics includes age, gender, residence, occupation, marital status and educational level. The majority (61.5%) of patients lies within the age of 20-40 years, 71.4% of them were females, 81.3% of them came from urban area, 51.6% of them were unemployed,46.2% of them were married and only 27.4% have had higher education.

Discussion:
Conversion disorders are part of the somatoform disorders that affect all age groups; the results of this study show that the prevalence of this disorder is different among different age groups and the most afflicted group is among the 20-40 year olds (112 patient 61.5%), from which 100 patients were between 20-30 years old (54.9%). The age differences seen in this study is approximate to the incidence shown by Deka et al ;in their study that was undertaken in India, the highest incidence was in the age group between 18-29 years age group (57.5%)[8]. Although several studies show even higher incidence in this age group[9][10] , other studies suggest higher incidence in late thirties [11].
Conversion disorder affects both sexes but it unequivocally affects females more than males, and in our study 71.4% of patients are female; some studies show even higher incidence in female [8][11][12].
In the present study 148 patients (81.3%) were living in urban area, a result that is concordant with the other studies [9]. It seems that one of the major causes in the wide differences in the incidence between urban and rural area is that this study was undertaken in the main Hospital in the city (Marjan Teaching Hospital) rather than district hospitals. Being unemployed, in 94 patients (51.6%), seem to confer higher incidence of conversion disorder than the other groups. Unemployment, undoubtedly, represents a major stress on the patient resulting from poverty, overcrowded households and dependence on others and these data are in agreement with other studies [9][10] , while the Indian study by Deka et al shows higher incidence among students [8].Married people show higher incidence of conversion disorder than the other groups in our study and they also show higher stress scores (table 3 ). Higher incidence among married people was shown also in other studies [9][10] while another study show higher incidence among unmarried [8]. Highest incidence of conversion disorder is seen among those whose education was limited to primary (34.1%) and secondary school (35.2%); Anradha et al study shows that the highest incidence among postgraduate level then among Secondary and primary school level [9].
Psychogenic non-epileptic seizures (P-NES) were the most frequent presentation of conversion disorder in our study, 70.3%, (Figure 3). P-NES is known to be one of the common presentations of conversion disorder in children and adults. Among P-NES, psychogenic falls and unresponsiveness were more common than convulsive type in our study; other studies seems to support these findings [8][13][14].
Most cases in the present study were previously admitted to the hospital in the Emergency Department or the medical wards (76.9%), while only 31.9% of them presented with history of previous visit to psychiatrist, emphasizing the fact that a significant proportion of those patients fail to be detected and diagnosed in the medical wards or at least they did not get proper treatment.
Conversion disorder may show multiple episodes and this seems to depend on the patient’s coping mechanism and the amplitude and multitude of stressors [15]. In our study we see that only 31.9% of the patients have ever received proper Psychiatric evaluation and therapy and this may also increase the risk of recurrence of the symptoms due to the lack of the knowledge about the nature of this disorder and the role of the stressors.
Couprie et al supports a better prognosis for conversion disorder other than Pseudo seizures, with 41% of patients going into relapses or having another episode [16].
Although the Majority of the sample (61.5%) presented with low to moderate risk of becoming ill in the near future, it is noticeable that the majority have previous episode of conversion disorder (76.9 %). In essence, this means that conversion episodes might be triggered at even lower scores than other mental illness which could be explained by the fact that most of the sample did not receive proper psychiatric treatment. The landmark study by Couprie et al has suggested that the more significant the improvement on discharge and the stronger identifiable stressor, the more likely it is that the patient will have better prognosis on the long term [16].
There was significant association between score interpretation and age, gender, occupation and marital status, while there was no significant association between score interpretation and other study variables. The highest score was among males .40-60 year old, those who live in urban area, non-governmental employees, divorced , illiterates and then those with higher education. There was no significant association between score interpretation and clinical presentation among patients with conversion disorder in our study.
Further studies are paramount to follow up these patients in order to elucidate the rate of recurrence following the identification of stressors and counselling and /or pharmacotherapy.


References
1- Sadock BJ, Sadock VA. Kaplan, Sadock’s Synopsis of psychiatry. Lippincott Williams, wilkins 2007; 10th ed : p. 638-42.
2- Halligan,PW,Bass, C and Marshall, JC (eds) (2001). Contemporary approaches to the study of hysteria : clinical and theoretical perspectives. Oxford University Press.
3- American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV).Washington,DC: APA.
4- Engl, G. (1983) Conversion symptoms. In Signs and Symptoms:Applied Pathology, Physiology and Clinical Interpretation (6th ed. C.MacBryde). Philadelphia, PA: J. B. Lippincott.
5- Holmes TH, Rahe RH: The social readjustment rating scale. Psychosom Med 1967; 11:213-218.
6- Teasell, R. W. & Shapiro, A. P. (1994) Strategic­behavioral intervention in the treatment of chronic nonorganic motor disorders. American Journal of Physical Medicine a Rehabilitation, 73, 44–50.
7- Hurwitz, T. & Kosaka, B. (2001) Primary psychiatric disorders in patients with conversion. Journal of Depression and Anxiety, 4, 4–10.
8- Kamala Deka, Pranit K. Chaudhury, Kavery Bora, and Pranab Kalita. A study of clinical correlates and socio-demographic profile in conversion disorder. Indian J Psychiatry. 2007 Jul-Sep; 49(3): 205–207.
9- Anuradha ,Mona Srivastava ,Manushi Srivstava . A comparative study of psychosocial factors in male and female patients with Conversion disorder. Indian J. Preventive & Social Medicine Vol. 42 No.3, 2011
10- Balram Pandit ,Kunal Kumar ,J.S.Yadav , S.Kaur. Conversion disorder :Socio-demographic and Psychosocial correlates of patients presenting with nonepileptic events. Delhi Psychiatry Journal 2011, Vol.14 No.1.
11- Stefansson JG, Messina JA. Hysterical neurosis, conversion type :clinical and epidemiological considerations. Acta Psychiatr. Scand 1976;53:119-38.
12- Jon Stone, Charles Warlow and Michael Sharp. The symptom of functional weakness: A controlled study of 170 Patients. Brain Journal of Neurology. Brain 2010: 133; 1537-1551.
13- P Grattan-Smith, M Fairley, and P Procopis. Clinical features of conversion disorder. Arch Dis Child 1988 63: 408-414
14- Sri Sankar Chinta, Prahbhjot Malhi, Pratibha Singhi, and Sudesh Prabhakar. Clinical and psychosocial characteristics of children with nonepileptic seizures. Ann Indian Acad Neurol. 2008 Jul-Sep; 11(3): 159–163.
15- Mace CJ1, Trimble MR. Ten-year prognosis of conversion disorder. Br J Psychiatry. 1996 Sep;169(3):282-8.
16- W Couprie, E F Wijdicks, H G Rooijmans, and J van Gijn. Outcome in conversion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995 Jun; 58(6): 750–752.