People diagnosed with conversion symptoms often are confused, frightened, or shamed by the diagnosis. Their initial psychological management can be divided into explaining, exploring, and treating.24
Explaining Conversion and PS
To begin psychiatric treatment of patients with PS, it is important to explain the diagnosis in ways that educate the patient, provide a cognitive framework of understanding, reduce shame, and motivate willingness to undertake treatment. The first meeting with a mental health professional is critical. To accomplish these objectives, we recommend first using techniques to reduce shame and second providing a cognitive framework by using concrete metaphors for understanding conversion symptoms. To reduce shame and facilitate rapport, it is important initially to address anxiety about being perceived as weak or “crazy,” the role of stress, coping responses, and underlying emotions.
We recommend including the family in this discussion. Family disagreements over the meaning of symptoms are ameliorated when patient and family hear the same explanation. When family tension or conflict is a factor in the conversion symptom, these tensions and dynamics are readily observable in the interview and can be discussed later with the patient.25,26
Conversion symptoms are generated unconsciously and express unconscious emotions and conflict. Conversion disorder patients have alexithymia, or difficulty recognizing and verbally expressing emotions, and therefore experience their symptoms as involuntary and uncontrollable. As a result, it is important to provide a cognitive framework for understanding conversion that emphasizes the possibility of gaining control over symptoms. We have found simple metaphors are helpful in explaining these abstract concepts related to PS and are easily adapted for other conversion symptoms. For example, emotions stemming from life stresses or trauma can be compared with steam in a pressure cooker, with “seizures” acting as a safety valve. Another useful metaphor compares conversion symptoms with a coded message — a symbolic message in somatic language that could be understood if translated or decoded through therapy.
A third useful metaphor was suggested by Griffith et al.25 after they observed videotaped interviews in which patients with PS nearly always were the most silent members of their families. The authors identified “unspeakable dilemmas” that the patients were expressing somatically. In nearly half the cases, the dilemma was a realistic threat of physical or sexual assault to someone in the family. In other cases, the family tacitly silenced emotional expression via shame or guilt. These patients were in an unspeakable bind; to express their dilemma verbally might be dangerous to themselves or others. To escape would pose even greater emotional pain to them and might endanger someone else.
Most patients identify with some aspect of these metaphors. Common resistances include denial of stresses, family dilemmas or “double binds,” or unexpressed emotions. Denial is best handled with a calm suggestion to discuss more of the patient's life history. Inevitably, a number of stresses or conflicts emerge. Resistance to the concept of overcontrol of emotions can be handled gradually by noting when the patient answers questions about affect with a statement of cognition, or verbally noting when inappropriate smiling (la belle indifférence) recurrently accompanies discussion of emotionally painful topics. Clinicians should confront inappropriate smiling gently, persistently, and promptly. This increases the patients' awareness of their alexithymia and often elicits more appropriate affect.
Conversion disorder patients actually need to be reminded of the names of broad categories of emotions (eg, mad, sad, bad, glad, hurt, scared) and encouraged to express emotions verbally. A common resistance is disbelief that the mind could cause these somatic symptoms. We remind patients that their unconscious mind has been controlling their breathing, heart rate, and other body functions during the interview, and that automatic physical responses to sudden fright (eg, increased heart rate) are normal.
We find that denial of the psychological nature of conversion symptoms is a poor prognostic factor, especially when the family colludes with or is the proponent of this denial. In these cases, we recommend the clinician allow that “we can agree to disagree” but insist that treatment be undertaken until “we are both sure” what causes the symptoms. Conflict can be reduced by reminding patients that conversion is a “good news” diagnosis because PS are potentially 100% treatable and the patient could be weaned from anticonvulsants (if concomitant epilepsy is not present).27
The empathetic explanation of PS as an automatic outlet for intolerable affect is a powerful therapeutic tool. The cognitive framework of a metaphor helps patients feel less helpless and controlled by the symptoms. The explanation alone helps some patients immediately reduce their frequency of PS.
Exploring the Causes of PS
The second step in psychiatric management of PS is exploration of their cause in an individual patient. Psychoanalytic theory holds that conversion expresses internal conflict and denial of forbidden unconscious impulses or wishes that are converted to somatic expression. Janet linked conversion to trauma and dissociative mechanisms.28 Freud initially understood conversion (“hysteria”) to be a consequence of childhood sexual seduction, but later repudiated that understanding.29 We now understand conversion to be related to a wider array of conflicts and emotions.30–32 The conflicts that produce symptoms are wide ranging but fall into distinct categories that can be explored systematically.33–35
The lives of most conversion patients have been painful or traumatic.30,33,34,36,37 Their difficulties often begin in childhood and encompass multiple stresses and traumas. Symptom onset is a response to “last straw” stresses after years of heavy emotional burdens.35
Table 3 lists four common life-event and emotional patterns in a series of intensely studied patients with PS.34,35 These patterns can assist in understanding most patients with PS. In addition to looking at life-event patterns, physicians should assess the most common comorbid diagnoses found in studies of PS patients, including dissociative disorders, posttraumatic stress disorder (PTSD), major depression, and generalized anxiety disorder.38 Some patients have panic attacks that are mistaken for PS.38
Patterns of Life Events and Emotions That Contribute to Pseudoseizures34,35
Patients with PS often experience other conversion symptoms and somatoform disorders. Psychosis, malingering, and factitious disorders occur in patients with apparent PS but are uncommon.
Numerous authors have noted the association of PS with sexual trauma, incest, rape, physical abuse, and domestic violence.28–30,33,34,36,37,39,40 Not all people with PS have experienced abuse, but approximately 85% report trauma, often with corroboration from family members.33,39 Adequate evaluation of the cause of PS therefore requires open-ended, nonleading questions about trauma or abuse. We find the most common life pattern associated with PS is childhood physical, sexual, or severe emotional abuse that is dissociated and brought near consciousness by adulthood trauma or other reminders of the abuse.34 Reminders of past abuse may be symbolic (eg, genital pain after childbirth or gynecologic surgery in a rape or sexual abuse survivor), obvious (eg, moving near the place of one's child abuse, encountering a former abuser, death of a parental abuser) or subtle (eg, children reaching the age at which the patient was at onset of his or her abuse). These reminders reduce dissociative barriers.
Dissociated emotions and memories threaten to emerge in consciousness. PTSD symptoms and dissociative episodes increase, and may be expressed as re-experiencing trauma in flashbacks or amnestic episodes that resemble seizures.34,39 At times, dissociated alter ego states or personality states emerge in response to reminders of trauma and re-enact assaults during PS. This life pattern can be ascertained by taking a detailed history of the person's life, noting amnesia for substantial portions of childhood, or for episodes of time loss in adult domestic abuse or in current life.
These patients should be evaluated for PTSD, depression, and for dissociative amnesia and dissociative identity disorder. Their trauma is often chronic, varied, and extensive. Their families may deny trauma, punish discussion of it, or blame and shame the patient. Ordinary stresses also may add to tension. Not all trauma is abuse; severe accidents, crime victimization, nondomestic trauma, combat trauma, and traumatic bereavement may be relevant.
Treatment focuses on identifying the emotions that these events raise and exploring the trauma. If possible, exploration should be conducted through a number of sessions after the patient's supports and defenses have been stabilized.41,42 This is not always possible in the seizure clinic but should be the norm in ongoing outpatient psychiatric treatment. Interviewers should avoid leading or suggestive interview techniques when inquiring about trauma or events underlying childhood amnesia.43
A second life event pattern of unexpressed anger is seen in about 25% of PS patients, more in men than in women.34 These patients often report verbally or physically abusive families of origin where expression of anger by the patient is discouraged or even punished. These families typically either avoid anger and conflict or express anger violently. Patients from such families conclude that anger is either too dangerous to acknowledge or is expressed only through violence, so they suppress awareness of it. Commonly, they describe a critical family, cruel school teasing from peers, or childhood or adulthood physical battering or threats.
These patients often describe aggravating or enraging life situations with la belle indifférence or an inappropriate smile. They deny sensing or expressing anger, saying, “I don't get angry.” They endorse cognitive distortions about anger; only blind rage is recognized as anger, and it is feared as destructive. They minimize all other irritation as “frustration, not anger.”
These patients also express anxiety about psychological or physical harm if they disagreed with or became angry at abusive parents or spouses. They avoid conflict in nondangerous life situations. Their faces or their general musculature show tension or anger of which they are blithely unaware.
In a third life pattern, the PS of patients express overwhelming grief and sadness at multiple losses or an unresolvable bereavement.44 Some patients describe multiple deaths, or losses of jobs, marriages, relationships, homes, finances, and so on. They may have relatively intact emotional expression or may have cultural or personal inhibitions about crying or grieving (especially true of male patients).
Major depression often is present and adds to their emotional burden. Some have PTSD symptoms from traumatic losses (accidental or combat deaths). The death of abusive parents is difficult for victims and may trigger the onset or cessation of PS. Some patients benefit from visiting the gravesite or discussing ambivalence about the deceased before their seizures resolve. Patients may display unexpected emotional blandness about losses. Patients with multiple losses also should be screened for depression and PTSD.
Approximately 10% to 15% of patients with PS deny trauma or multiple losses and do not have obviously anger-engendering families. Their PS —often accompanied by other conversion symptoms such as muteness, dysphonic, weakness, numbness, or fainting — are an expression of family conflicts that are experienced as “double binds.” Even if they consciously perceive the family conflict, they see no emotionally acceptable answer to it and believe verbalization of it is also unacceptable. Emotional tension rises and depression or anxiety mount until a dissociative escape via conversion symptoms is their only solution. This focuses the family on the symptoms and eventually on discussion of the conflict after the patient verbalizes it in psychotherapy. These conflicts often involve duties, guilt, and family norms of interactions.
PS usually decrease sharply after the conflict is verbalized in individual psychotherapy and the patient is assisted in discussing it in family therapy. If the conflict centers on family secrets (such as incest), the trauma also must be addressed to resolve conversion symptoms.
These four life patterns associated with PS deal with life events associated with conversion but not its underlying mechanism of dissociation.34,45 Psychological dissociation is disconnection of mental processes from each other or from consciousness. Somatoform dissociation (another name for conversion) is disconnection of somatic (motor or sensory) control from conscious control.45,46
Many PS episodes represent dissociative detachment from the self and the environment in trance states or limp collapse with amnesia.47 These PS are simply staring episodes of autogenic trance states of dissociation that appear to be like absence epilepsy. During the evaluations of PS patients, they often can be observed to enter trance states (eg, staring, looking clouded or blank, even becoming unresponsive). A dynamic formulation of the cause of the seizures can be inferred by noting which topics or emotions elicit this dissociative response.
We advise interrupting the patients' entry into a trance by breaking their staring gaze, advising them to move their bodies and alert themselves. Patients can be taught to recognize their entry into trance, which often precedes their conversion symptoms, and how to avoid such entry. This may be their first experience of gaining some control over symptom occurrence. When a pattern of association between trances and emotional themes is discerned, the patient can learn that trances and seizures are defensive patterns related to specific issues.
The International Statistical Classification of Diseases and Related Health Problems, 10th edition,48 classifies conversion as a dissociative disorder, substituting the word “dissociative” for “conversion.” Dissociation is nearly ubiquitous in PS patients but often is overlooked and not formally diagnosed. When a validated diagnostic instrument for dissociative disorders under criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV)49 — the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) — was used systematically, 90% of PS patients were found to have a dissociative disorder, usually dissociative amnesia.28,50 Dissociative amnesia is extremely common during PS, occuring in about 80% of patients at times other than during seizure spells.39 When systematic inquiry is undertaken, up to half of PS patients are found to have a dissociated ego state that will admit to causing the seizures.39 PS patients dissociate affect and often dissociate behaviors (flashbacks) and memories. We recommend screening all PS patients for dissociative symptoms and disorders such as amnesia, depersonalization, derealization, and identity alteration. The screening questions of the SCID-D are useful for diagnosing dissociative disorders.50
In a significant minority of patients, PS are dissociative re-enactments of sexual or physical trauma by dissociated ego states or personalities in patients with dissociative disorder – not otherwise specified, dissociative identity disorder, or complex PTSD. This situation is unlikely to be addressed in treatment unless a formal evaluation of dissociation has been conducted. Evaluations should be completed over several sessions to avoid flooding patients with panic from rapid awareness of having dissociative lapses. We screen all PS patients with the self-report Dissociative Experiences Scale (DES) and carefully screen for complex dissociative disorders when DES scores are higher than 30.51,52 All PS patients who report significant trauma should be screened for PTSD in addition to dissociative disorders.
In summary, patients with PS should be evaluated for a variety of life stresses and traumas in childhood and adulthood, for the presence of unexpressed painful emotions, and for cognitive and defensive patterns that inhibit verbal and affective expression of their distress. In addition, clinicians should screen for the common comorbid illnesses of dissociative disorders, PTSD, major depression, panic disorder, generalized anxiety disorder, and family relationship binds.