Return of the Repressed: Is a Mysterious Outbreak of Mass Hysteria Proving Freud Right?
What is Conversion Disorder?
Posted Feb 05, 2012
Assuming (though it is too soon to tell) no clear toxic environmental, infectious or neurological cause is discovered, these extraordinary cases dramatically demonstrate the uncanny power of what Freud called the "unconscious," that which we chronically exclude from consciousness, in creating somatic symptoms like involuntary twitching, stuttering, swearing, seizures (as seen typically in Tourette's Syndrome or temporal lobe epilepsy) and so many of the other physical symptoms ordinary patients regularly bring to their general medical practitioner for treatment. In an era in which so many mental health professionals and consumers deny the very existence and importance of the unconscious in the etiology and treatment of mental disorders, such relatively rare cases serve to illustrate its undeniable presence and impressive power to non-believers, in much the same way a miracle might confront the atheist or agnostic with God's reality.
Several centuries ago, such suddenly stricken individuals would have been deemed victims of demonic possession, and treated with exorcism. (See my prior post.) Or witches, and burned at the stake, tortured or drowned to death. Their strange symptoms were seen as supernatural. How else could such bizarre behavior be explained by our ancestors? Freud's revolutionary "psychology of the unconscious" sought to scientifically explain not only those phenomena previously attributed to demonism, witchcraft and the supernatural, but to the somatogenic or physiological model of psychopathology predominant in Western psychiatry during the nineteenth century. Even now, a century after Freud, we resist recognizing that these sort of symptoms (and so many more) can be psychologically rather than neurologically caused. Unfortunately, we have regressed to a pre-Freudian Weltanschauung, throwing the Freudian baby (the unconscious) out with the bathwater (psychoanalysis). Some still consider such maladies signs of satanic possession. Others in the medical field insist that the problem must reside in faulty neurology or physiology. Bad biochemistry. A "broken brain." To admit the capacity of the unconscious or daimonic to take temporary or chronic possession of our bodies or brains is just too threatening to the ego and our precious scientific rationality. But when cutting-edge medical science fails to explain such mystifying phenomena, when all possible physiological and environmental causes have been carefully ruled out and systematically eliminated, there remains only one clear scientific conclusion: Behold and be humbled by the awesome power of psychology. And of the unconscious. What do CBT practitioners and biological psychiatry have to say about that!? It looks like Herr Doktor Freud may posthumously have the last laugh.
In the case of Ana O., Freud, a physician and neurologist, famously discussed the impressive phenomenon of hysterical conversion as it manifests in so-called "glove anesthesia," a condition in which the patient's subjective loss of feeling in a wrist and hand would be neurologically and anatomically impossible. And it was Freud himself who replaced the archaic and sexist term hysteria in describing the symptoms of this syndrome with that of conversion. Psychiatrically speaking, once all other medical or environmental explanations have been dismissed, the peculiar symptoms collectively displayed by the now famous "Le Roy fifteen" are seen by some as falling today into the general category of Somatoform Disorders, and specifically to conform to the diagnosis of Conversion Disorder. (A diagnosis of Tourette's Disorder or Chronic Motor or Vocal Tic Disorder requires symptoms to have been present for more than one year. However, in Transient Tic Disorder, symptoms by definition endure no longer than one year, and begin prior to the age of 18, as in most of these cases. So, it seems to me that, based on the symptoms, this diagnosis must also be considered.) What is Conversion Disorder?
Conversion Disorder is considered one of several so-called "somatoform disorders" by DSM-IV-TR, connoting the interconnection between mind and body, psyche and soma. (The term psychosomatic refers to this integral link between body and mind, but does not technically apply to all conversion symptoms.) Somatoform disorders are distinguished by physical symptoms such as pain, sexual dysfunction, gastrointestinal distress, urinary retention, double vision, blindness, deafness, seizures, paralysis and other seemingly neurologically-based symptoms. But, by definition, such symptoms, after appropriate examination, have no neurological basis and cannot be fully explained by any known general medical condition or the direct effects of any external or ingested substance. In Conversion Disorder specifically, these medically inexplicable pseudoneurological symptoms are typically preceded by serious psychological conflicts, trauma or other significant psychosocial stressors. Conversion Disorder differs from Malingering or Factitious Disorder insofar as the symptoms are not intentionally, deliberately or consciously produced or feigned. Moreover, the debilitating and clinically significant symptom or symptoms cannot be fully explained culturally or religiously, is not limited to pain or sexual dysfunction, and cannot be better accounted for by some other diagnosable mental disorder (e.g., Schizophrenia, Major Depression or Obsessive-Compulsive Disorder). According to DSM-IV-TR, there are three different types of Conversion Disorder, depending upon the particular pattern of symptoms presented. The less sophisticated the patient regarding physiology and neurology, the more incredible, less subtle and medically implausible the presenting symptoms tend to be. Historically, and importantly, Conversion Disorder was frequently misdiagnosed in as many as half of patients who were eventually found to be suffering from some legitimate medical condition. Moreover, "as many as one-third of individuals with conversion symptoms have a current or prior neurological condition." But Conversion Disorder--like, for example, Dissociative Identity Disorder or Shared Psychotic Disorder (see my prior post)--definitely does exist as a legitimate, non-neurological, psycholological phenomenon.
DSM-IV-TR (see my prior post) notes that, in the case of psychogenic contagion or so-called epidemic hysteria, "shared symptoms develop in a circumscribed group of people following 'exposure' to a common precipitant." What could that "common precipitant" have been? In some cases, witnessing such symptoms in one person can become the catalyst to their appearance in others. Curiously, Conversion Disorder (originally termed by Hippocrates hysteria, meaning "wandering womb") is much more common in women than men, with symptoms appearing primarily on the left rather than right side of their bodies. It typically (though not always) occurs some time between the ages of 10 and 35, and symptoms, though acute and escalating initially, frequently (but not always) tend to remit within several weeks or months.
As the DSM-IV-TR, that treasure trove of clinical wisdom, further succinctly explains, psychodynamic theory (derived from Freud) holds that "the individual's somatic symptom represents a symbolic resolution of an unconscious psychological conflict, reducing anxiety and serving to keep the conflict out of awareness." In other words, conversion symptoms convert dissociated unconscious feelings or impulses into physical symptoms. Strange but true. This conversion occurs unconsciously, which is to say that the person experiencing symptoms is unaware that this is happening. Unconscious of the psychological significance of their symptoms. This is because conversion is an unconscious defense mechanism. For them, such symptoms seem to appear out of nowhere, and are experienced as totally alien to themselves, completely out of character, and not subject to their own will. (One of the Le Roy teens says she felt fine, took a nap, and woke up stuttering.) Conversion Disorder is believed to occur primarily in societies with repressive social systems that prevent individuals from openly expressing feelings and emotions toward others. Transitory somatic symptoms and behaviors can serve as indirect and symbolic attempts at communication, particularly for those who are chronically oppressed, marginalized, neglected, ignored or feel they have no voice or real say in their lives. Their bizarre symptoms, like dreams, become a passive yet dramatic and attention-demanding way of symbolically expressing what is unconsciously churning in their troubled psyches, masked beneath their public persona.
Here are two cases cited in a relatively recent article (2006) titled Conversion disorder: the modern hysteria by Colm Owens and Simon Dein:
"A 24-year-old cleaner had an argument with his boss. Shortly afterwards he developed weakness of his right arm and an inability to talk. He was brought to an accident and emergency department. A full neurological examination, including a number of blood tests and a lumbar puncture, showed no specific abnormalities. His computed tomography (CT) and magnetic resonance imaging (MRI) scans were normal. His symptoms did not improve after a week in hospital. Finally, he was offered two sessions of hypnosis. His symptoms resolved completely at the end of the second session."
"A 30-year-old African woman was the victim of an assault. She received a severe blow to her head and lost consciousness for about a minute. She subsequently developed weakness on the left side of her body, in both her arm and leg, and loss of vision in her left eye. She underwent thorough investigation at her local hospital, including a CT and MRI scan. Nothing abnormal was found. In several interviews with a psychiatrist she disclosed that she had been brought up unable to express anger. During a session of abreaction, she became very over-aroused and started screaming. Following this she slowly regained the use of her left arm and leg. It seemed apparent that her symptoms were the result of her inability to express anger."
Note that in both of these clinical vignettes, the individuals suffering from conversion symptoms, one male and the other female, were having difficulties dealing with anger : In the first case, the man had been in an argument with his boss just prior to the onset of his symptoms. In the second, the woman apparently had to repress her anger since childhood. (See my prior posts.) Whether the treatment approach is hypnotherapy, psychodynamic psychotherapy, existential therapy, CBT, DBT or, for that matter, exorcism, some adequate affective expression of repressed anger, rage or other conflictual feelings is necessary if progress is to be made. This was precisely Freud's point in his 1895 publication, Studies on Hysteria. He called it abreaction. And, if the diagnosis of Conversion Disorder proves valid, this will hold true in the effective treatment of these fifteen troubled teenagers (and one thirty-something woman) in Le Roy. All of whom have reportedly experienced some significant recent trauma in their lives. If I were treating them, I would want to know what the meaning of their strange symptomatic behaviors might be: Are they indicative of a frustrated need for attention? If so, they are succeeding wildly, with the news media's intense focus on their plight. Unfortunately, such attention can serve to reinforce and perpetuate their symptoms. Or might their remarkable symptoms be saying something about how they are really feeling inside, but unable or unwilling to allow themselves to consciously acknowledge, feel or verbalize? Are they angry? If so, what about? Are they sad? Scared? Depressed? Anxious? Lonely? Having severe family or social difficulties? So isolated, alienated and desperate for some sense of belonging that they would unconsciously adopt certain unusual symptoms in an effort to conform to their perceived peer group? Or to stand out from others? What could the unconscious be trying to tell them via the creation of these painful, frightening and embarassing symptoms?
Helping such patients discover the psychological meaning of their symptoms and what underlies them is the key to treatment. Educating them about the nature and power of the unconscious. But, of course, such patients are resistant (just like the rest of us, doctors included) to seeing their symptoms as psychological rather than neurological or toxicological. (It is always preferable to be able to blame our problems on biology, genetics, biochemistry neurology, society or others than to take personal responsibility for their presence and amelioration.) That's human nature. For them, this resistance is part and parcel of Conversion Disorder. They must deny the psychological nature of their symptoms, since the symptoms themselves are designed to deny and defend against the underlying psychological conflicts. No one wants to hear that their physical suffering is "all in your head." Which is how a diagnosis of Conversion Disorder is commonly taken. They experience such diagnostic explanations as dismissive and demeaning of their physical suffering. Which is very real. And they resist any notion of the existence of some unknown, "unconscious" part of themselves that could be capable of abruptly producing such devastating physical symptoms against their conscious will. Yet, incredible as it sounds, that may very well be precisely what is happening.