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Conversiestoornis
Abstract
Onder de conversiestoornis worden pseudo-neurologische aandoeningen verstaan, die zich manifesteren op motorisch of zintuiglijk gebied. Pseudo-neurologisch, omdat de klacht een neurologische ziekte doet vermoeden, terwijl daar bij onderzoek geen aanwijzingen voor worden gevonden en het dus gaat om verschijnselen niet van organische maar van psychische oorsprong. De conversiestoornis is van oudsher bekend onder de naam hysterie of conversiehysterie (Charcot, 1991). Een ziektebeeld dat vroeger, en nog steeds, door vele artsen werd en wordt opgevat als een wat bijzondere vorm van aanstellerij. Ten onrechte: niet voor niets is in de dsm-iv (American Psychiatric Association (apa), 1994) het diagnostisch criterium ’de verschijnselen zijn niet opzettelijk opgewekt of geveinsd' opgenomen. Conversiepatiënten met een verlamming beleven hun verlamming niet anders dan neurologische patiënten: zij kunnen evenmin hun been in beweging brengen.
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There are many similarities between the symptoms of conversion hysteria and phenomena produced in hypnotic contexts. This paper reviews some of those similarities and considers more general features associated with both hypnotic phenomena and conversion hysteria symptoms such as lack of concern, perceived involuntariness, the display of ''implicit knowledge'' and their apparently compliant nature. Neurophysiological and brain-imaging studies of hypnotically produced effects and conversion symptoms are described, which implicate frontal cortical structures in moderating the respective changes elsewhere in the brain, particularly in cingulate cortex. A recurrent theme is the apparent paradox which exists between, on the one hand, the subjective reality and involuntariness of both hypnotic phenomena and the symptoms of conversion hysteria and, on the other, the fact that objectively they appear to be role-congruent enactments responsive to the manipulation of motivational factors, expectancy, and social influence. A model of consciousness and self-awareness is presented which attempts to resolve that paradox whilst describing similar mechanisms underlying hypnotic phenomena and conversion hysteria symptoms. The model develops the idea of a central executive structure, similar to the notion of a supervisory attentional system, acting outside self-awareness but at a late stage of information processing which can be directly influenced from both internal and external sources to produce the relevant phenomena. The paper ends by proposing that as conversion disorder, pain disorder, and the dissociation disorders appear to be linked by a common mechanism they should be classified together under the heading of auto-suggestive disorder.
"Hysterical means psychogenic patterns of reactions in which a tendency to dissimulate finds expression through an instinctive, reflexive, or other built-in survival mechanism." This tenet is illustrated with stress reactions in animals, primitive people, and excerpts from case-histories, and viewed as "multiple irradiation and cascade effects psycho-reactively forged between drives and vegetative and metabolic controls." (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Conversion symptoms, as identified by the existing classification systems, do not form a single unitary class. It is therefore difficult to find an adequate treatment that closely connects to the basic characteristics of the disease. Instead, we designed a treatment method that closely relates to the behavioural aspects of a conversion disorder. We reasoned that motor patterns can be taught straightforwardly by means of operant conditioning methods and that movement disorders in conversion should be treated accordingly. Our case study shows that carefully retraining deficient motor patterns may constitute the core of the treatment for conversion disorders.
Patiënten met een conversiestoornis met insulten worden vaak ten onrechte als lijdend aan epilepsie gediagnosticeerd. De standaardprocedure
voor de diagnose is het afnemen van een EEG bij de patiënt tijdens zo'n aanval. Toch komt het voor dat deze procedure geen afdoende uitsluitsel geeft. In dit artikel
wordt een diagnostische procedure beschreven waarbij de therapeut een insult probeert op te wekken bij de patiënt bij wie
een conversiestoornis vermoed wordt. Wanneer patiënten vervolgens een dergelijke aanval krijgen is het een methode die ertoe
kan bijdragen conversieve insulten te onderscheiden van epileptische.
Background:
The percentage of patients initially diagnosed with a conversion disorder and later identified as having an organic disorder has been decreasing in recent studies.
Method:
Consecutive patients with a diagnosis of conversion disorder were referred for psychiatric diagnosis and treatment. Research questions were: (1) What incidence of neurological disorder is revealed by neurological reassessment and by which diagnostic technique is the final diagnosis established? (2) What differences can be observed between true-positive and the false-positive results?
Results:
Ten (11.8%) of the 85 patients examined appeared to suffer from a neurological disorder. In this sample, variables discriminating between the true positives and false positives were: (1) prior suspicion of neurological disorder; (2) older age at referral; (3) older age at onset of symptoms; (4) longer duration of symptoms; and (5) use of medication. Three variables contributed significantly to the prediction of organic disorder: prior suspicion of neurological disorder; age at onset of symptoms; and duration of symptoms.
Conclusions:
Although our results are in line with those of other recent studies, the percentage of false positives was still high. The data further emphasize the dangers of making a diagnosis of conversion disorder in the absence of positive evidence. It is important to continue to provide follow up for patients with a diagnosis of conversion disorder. Unfortunately, unreliable psychiatric indications, like certain behavioral characteristics, are still used in the diagnostic process. The results show that a general neurological examination is still a valuable diagnostic instrument in addition to modern diagnostic techniques.
Analysis of 1,000 consecutive psychiatric consultations shows that the prevalence of conversion disorder (5%) in a general hospital remains significant. Conversion patients referred for psychiatric consultation were predominantly married young women of lower socioeconomic class and rural background. We observed rapid remissions of presenting symptoms in most cases upon treatment and found a significant proportion of somatization disorder (34%) or history of conversion disorder (38%). Other phenomenologic findings are discussed in regard to previous reports or hypotheses about conversion symptoms.
Mystical states by-pass usual sensory perception and logical thinking. They often represent the ultimate goal of long apprenticeships in Eastern or Western monastic practices which stress selfdiscipline and meditation; or they correlate with sudden religious conversions. While interest has also been revived in mystical experiences stimulated by hallucinogens within the appropriate physical, intellectual, and emotional environment, less attention has been paid to those mystical experiences which appear spontaneously during hypnosis and Transcendental Meditation. The present author facilitates the unleashing of mystical experiences by using hypnotic approaches specifically aimed at altering space and time perceptions. Case presentations illustrate the methodologies for guiding receptive subjects to mystical states with the aim of relieving or correcting organic and functional painful syndromes unresponsive to other interventions. The probable biopsychological processes are discussed.
Although somatization disorder and conversion disorder are linked in DSM-III and DSM-III-R, they have very different histories. To directly compare these disorders, we reviewed the records accrued for 2 years at a large medical center and identified 65 somatization disorder patients and 51 conversion disorder patients. They differed substantially. The large majority (78%) of conversion disorder patients and nearly all (95%) of the somatization disorder patients were women. Ages at onset occurred throughout the life span among conversion disorder patients but mostly before the age of 21 among the somatization disorder patients. Somatization disorder patients were more likely to have had a history of depression, attempted suicide, panic disorder and divorce.
Levi-Strauss (1977) describes what happened to a child, in a primitive tribe, accused of sorcery–a crime punishable by death. The child invented more and more complex stories by way of self-justification. In the end his accusers believed his outlandish explanation because “the choice is not between this system and another but between this system and no system at all-chaos.” The child's plight can represent the close affinity between magic and hysteria; his accusers might represent those contemporary psychiatrists who would prefer any system of classification of hysteria, however absurd, to no system at all (Sheehan & Sheehan, 1982 a, b ; DSM-III, 1980).
The authors were impressed with the relatively high incidence of "classical" conversion reactions among troops evacuated to a psychiatric referral center in the Philippines following combat service in Viet Nam. Social and environmental pressures seemed to be significant both in precipitating the symptoms and in the form the symptoms took. The authors speculate as to whether the cases reflect the patient's response to a recent traumatic event or an attempt to explain an emotional conflict of prior existence in a socially acceptable way.
This is a study of the symptoms and treatment of 61 patients with hysterical conversion. The incidence rate is high and the clinical picture showed different qualities from that seen in other studies. Treatment by suggestion under various procedures produced favourable results. All symptoms were removed and after twelve months follow-up only 12 patients relapsed. Symptom substitution was minimal. The prognosis is related, among other things, to the duration of the symptoms before treatment.
Nonepileptic seizures (NES) must be distinguished from epilepsy to avoid the adverse effects of unnecessary antiepileptic drugs and to initiate appropriate psychiatric treatment. A higher frequency of prior sexual abuse has been suspected in NES, although no prospective controlled study has compared patients with NES and epilepsy. A series of patients with conversion disorder presenting as epilepsy and 140 patients with complex partial epilepsy (CPE) without evidence of conversion were selected from a series of consecutive admissions to a comprehensive epilepsy center. The groups did not differ with respect to age, years of education, race, or marital status, but the percentage of women was greater in the conversion NES group (73.2%) than in the CPE control group (50.7%; p < 0.002). The frequency of a history of sexual or physical abuse was greater in the NES group (32.4%) than in the CPE controls (8.6%; p < 0.000). Severity of sexual but not physical abuse was significantly greater in the NES group relative to controls (p < 0.05). There was a trend for a closer relationship of the perpetrator of sexual abuse to the victim among the NES patients compared with CPE controls (p < 0.1). These results support the impression that childhood abuse is more common among patients with conversion NES than with epilepsy, and suggests that in some cases childhood abuse may be a contributory pathogenetic factor.
The goal of this study was to determine current and lifetime rates of DSM-III-R disorders in patients with pseudoseizures and to ascertain whether trauma is associated with the occurrence of pseudoseizures.
Adult pseudoseizure patients (N = 45) were interviewed regarding seizure course and life events, and they were given the Structured Clinical Interview for DSM-III-R--Patient Version, the Structured Clinical Interview for DSM-III-R Dissociative Disorders, the Dissociative Experiences Scale, and the Personality Diagnostic Questionnaire--Revised. The pseudoseizures were diagnosed in a tertiary-care video-EEG facility. Most of the subjects (78%) were female, and the mean age of the overall patient group was 37.5 years (SD = 9.7).
The mean duration of the subjects' seizure history was 8.3 years (SD = 8.0). Common current psychiatric diagnoses included somatoform disorders (89%), dissociative disorders (91%), affective disorders (64%), personality disorders (62%), posttraumatic stress disorder (PTSD) (49%), and other anxiety disorders (47%). The lifetime occurrence of nonseizure conversion disorders was 82%. The mean Dissociative Experiences Scale score was 20.2 (SD = 18.2). Trauma was reported by 84% of the subjects: sexual abuse by 67%, physical abuse by 67%, and other traumas by 73%.
Pseudoseizure subjects have high rates of the psychiatric disorders found in traumatized groups; they closely resemble patients with dissociative disorders. Reclassification of conversion seizures with the dissociative disorders should be considered. Pseudoseizures often appear to express distress related to abuse reports. Clinicians should screen pseudoseizure patients for adult and childhood trauma, dissociative disorders, depression, and PTSD.
The concept of a conversion disorder (such as hysterical paralysis) has always been controversial (Ron, M.A. (1996). Somatization and conversion disorders. In: B.S. Fogel, R.B. Schiffer & S.M. Rao (Eds.), Neuropsychiatry. Williams and Wilkins, Baltimore, MD). Although the diagnosis is recognised by current psychiatric taxonomies, many physicians still regard such disorders either as feigned or as failure to find the responsible organic cause for the patient's symptoms. We report a woman with left sided paralysis (and without somatosensory loss) in whom no organic disease or structural lesion could be found. By contrast, psychological trauma was associated with the onset and recurrent exacerbation of her hemiparalysis. We recorded brain activity when the patient prepared to move and tried to move her paralysed (left) leg and when she prepared to move and did move her good (right) leg. Preparing to move or moving her good leg, and also preparing to move her paralysed leg, activated motor and/or premotor areas previously described with movement preparation and execution. The attempt to move the paralysed leg failed to activate right primary motor cortex. Instead, the right orbito-frontal and right anterior cingulate cortex were significantly activated. We suggest that these two areas inhibit prefrontal (willed) effects on the right primary motor cortex when the patient tries to move her left leg.
In a single case study with positron emission tomography (PET) functional imaging, hypnotic paralysis activated similar brain areas to those in conversion hysteria, supporting the view that hypnosis and hysteria might share common neurophysiological mechanisms.
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