Hysteria – Conversion Disorder – Functional Neurological Disorder

           Somatoform disorders are characterized by physical symptoms that suggest a medical condition but that are not fully explained by a medical condition (Woolfolk, 2012) (see table 1). Functional neurological disorder, also known as conversion disorder – historical name is hysteria- is a kind of somatoform disorder that has unexplained neurological symptoms. Conversion disorder tends to be chronic. Conversion disorders often take the form of an acute episode. Symptoms may remit within a few weeks of an initial episode and they may recur in the future (Woolfolk, 2012).

Table 1. Somatoform Disorders 1980 - 2016
DSM-III	DSM-III-R	DSM-IV	DSM-5
Somatization disorder	Somatization disorder	Somatization disorder	Complex somatic symptom dis. Simple somatic symptom dis. Illness anxiety disorder
Hypochondriasis	Hypochondriasis	Hypochondriasis
Psychogenic pain disorder	Somatoform pain disorder	Pain disorder
	Undifferentiated somatoform disorder	Undifferentiated somatoform disorder
Conversion disorder	Conversion disorder	Conversion disorder	Neurological Functional Disorder
Atypical somatoform disorder	Body dysmorphic disorder	Body dysmorphic disorder
	Somatoform disorder	Somatoform disorder
			Psychological factors affecting medical condition

             Symptoms of conversion disorders are common and can be associated with significant consequences. Early in the history of psychiatry, symptoms of paralysis, somnambulism, convulse attacks, psychogenic blindness, and mutisms are reported most commonly. Conversion disorders may mimic many other neurological and medical disorders (Maldonado, 2007).

The term “conversion disorder”, as used in DSM-IV-TR, describes symptoms such as weakness, epileptic-type attacks, abnormal movements or sensory disturbances that are not attributable to a structural damage to the nervous system or to feigning and that are considered to be associated with psychological factors.

Recent studies suggest that the large majority (78%) of conversion disorder patients and nearly all (95%) of the somatisation disorder patients were women. (Tomasson et al. 1991). Most of the conversion disorder patient see emergency department with neurological symptoms. Conversion disorders often related to other psychological disorders such as, major depression, anxiety, post-traumatic stress disorders, panic attacks. Personality disorders are not common in patient with conversion disorders (Gabbard, 2001). Moreover, patients with conversion disorders have an increased attention to the self and a decreased agency (Demartini et al. 2015). 

The symptoms of conversion disorders may appear to serve a number of unconscious purposes, such as the expression of forbidden wishes or impulses in a masked form, the imposition of self-punishment via a disabling symptom for a forbidden wish or wrongdoing, or the removal of oneself from an overwhelming, life-threatening situation. (Maldonado, 2007). Symptoms of conversion disorders are conscious but motivation is unconscious. (Cottencin, 2014)

In conversion disorder, production of symptoms and motivation are unconscious phenomena and benefits are both primary and secondary as summarized by Zumbrummen (see Table 2).

Table 2. Differences between somatic disease, somatoform disorder, factitious and malingering.
	Somatic diseases	Somatoform disorder	Factitious disorder	Malingering
Subjective symptoms	+	+	+	+
Objective symptoms	+	_	(+)	_
Voluntary	_	_	+	+
Benefits	?	Internal External	Internal	External
From Zumbrunnen R, Psychiatrie de liaison, Masson., Paris, 1991

Doctors of the patients with conversion disorders should summarize the diagnosis and be convinced of it; announce the diagnosis to the patient; and help the patient to engage in psychotherapy.  The first therapeutic steps should involve active research for a physical illness. Diagnosis of conversion disorder is very difficult. First of all, physician must control the potential un-psychological diseases. Moreover physician should use EEG, EMG etc.

Today conversion disorder is still stigmatized, being frequently associated with lying or malingering. However, conversion disorders definitions have long existed, but this still generally fail to overcome the a priori assumptions of doctors, other paraclinical personal and family of patients. (Cottencin, 2014)

Conversion disorder (DSM-IV-TR) is a name of the disorders change in DSM-5 to Functional Neurological Symptom disorder. Therefore, patients have started feeling themselves as genuine patients because the new “functional neurological symptom disorders” name and definition have started giving them that dignity they have never felt (Demartini, 2016).

In order to identify the pathophysiological hypotheses of conversion disorder, clinical neurophysiology is now implementing the models, methodologies and techniques of the current scientific approach .It should be emphasized that since the 1970’s, remarkable developments, both formal and empirical, have occurred. Significant advances in the general theories of cognitive functions involved in hysteria, implementation of sophisticated cognitive tasks, spatial and temporal resolutions of imaging techniques; study of connectivity and so on. (Crommelinck, 2014)

            Pierre Briquet (1796-1881) defended the essentially neurocerebral origin of the hysteria disease, rather than the “uterine” one. It should be noted that the “uterine theory” was still defended in the 1850s in particular by Pierre Adolphe Piorryy (1794 – 1879) whom the seat of hysteria was the ovary in women and the spermatic cord or testicles in men.

            John Russell Reynolds (1828 – 1896) published an important article on case studies of hysteria, “Remarks on paralysis and other disorders of motion and sensation dependent on idea”. His hypothesis was to be later resumed by many authors such as Janet and Freud.

            Jean – Martin Charcot (1825 – 1893) referred top hypnosis a method for the experimental study of hysteria, and tried to apply the clinicopathological method.

            Sigmund Freud (1856 – 1939) published the “Studies on Hysteria” with J. Breuer (1844-1925). Freud formulated the conceptual of hysteria that psychologist use this formulation long time. Since the end of 1960s, hysteria integrated the cognitive science. These changes were conceptual, methodological and technical.

            Today’s different areas handled conversion disorders (functional neurological symptom disorders) with several perspectives such behaviourism, cognitive-behavioural perceptive, cognitive neuroscience, philosophy of mind.

Conversion disorder is costly to the health care system, especially when symptoms are chronic (Mace & Trimble, 1996). Patients with long-standing conversion symptoms are likely to submit themselves to unnecessary diagnostic and medical procedures. Martin and colleagues reported an average of $100,000 being spent per year per conversion disorder patient (Martin, Bell, Hermann, & Mennemeyer, 2003).

            There are several steps to comprehensive treatment of patients with conversion disorders. First step is a thorough neurological and medical issue. In the beginning, Patient’s complaints and explanations of his/her subjective symptoms should listening. Physician should give attention the patients symptoms who explain own self, because, main drivers of conversion disorders are patients subjective feelings and beliefs rather than symptom that are found by physician.

            Second point is about proficiency and education of physician. Physician must have enough information about conversion disorders to refer psychologist or psychiatrist. (Cottencin, 2016)

            Explaining the diseases to patents is important part of treatment. Indeed, many psychologists think that diagnostic label is not useful, but unexplained diseases can be huge stress factors (Stonnington, 2006).  Moreover, physician motivates the patient to get psychotherapy.

            Working with the family unit may be necessary when family and socio-cultural factors predominate, particularly in children and adolescents. Family therapy interventions can help the patient and family recognize key issues that may be fuelling the symptoms.

           

References

Cottencin, O., (2014). Conversion disorders: Psychiatric and psychotherapeutic aspects.  Clinical Neurophysiology, 44, 405-410.

Crommelinck, M., (2014). Neurophysiology of conversion disorders: A historical perspective. Cinical Neurophysiology, 44, 315-321.

Demartini, B., (2016). From conversion disorder (DSM-IV-TR) to functional neurological symptom disorder (DSM-5): When a label changes the perspective for the neurologist, the psychiatrist and the patient. Journal of the Neurological Sciences, 360, 55-56

Diagnostic and statistical manual of mental disorders: dsm-5-5^th ed. American Psychiatric Association.

Demartini, B., Ricciardi, L., Crucianelli, L., Fotopoulou A., & Edwards, M., J. (2016). Sense of body ownership in patients affected by functional motor symptoms (conversion disorder). Consciousness and Cognition, 39, 70–76

Gabbard, O. G., Gabbard’s treatments of psychiatric disorders, 4^th ed. American Psychiatric Publishing, 2001; 37: 595-606

Martin, R., Bell, B., Hermann, B., & Mennemeyer, S. (2003). Non epileptic seizures and their costs: The role of neuropsychology. In G. P. Pritigano & N. H. Pliskin (Eds.), Clinical Neuropsychology and Cost Outcome Research 235-258. New York: Psychology Press.

Mace, C. J., & Trimble, M. R. (1996). Ten-year prognosis of conversion disorder. British Journal of Psychiatry, 169, 282-288.

Stonnington, C. M., Barry, J. J. & Fisher, R. S., (2006). Conversion Disorder.  Retrieved from: http://ajp.psychiatryonline.org/doi/pdf/10.1176/ajp.2006.163.9.1510

Voon, V., (2014). Functional neurological disorders: Imaging. Clinical Neurophysiology, 44, 339-342

Woolfolk R. L. And Allen L. A. (2012). Cognitive Behavioral Therapy for Somatoform Disorders, Standard and Innovative Strategies in Cognitive Behavior Therapy. Available from: http://www.intechopen.com/books/standard-and-innovativestrategies-in-cognitive-behavior-therapy/cognitive-behavioral-therapy-for-somatoform-disorders