Dr. H concluded that Nancy’s physical symptoms resulted from Conversion Disorder. Naturally, one may ask, what is “converted”?
And now, for the rest of the story of Nancy and Freud…
Having evolved a keen understanding of the subconscious, Freud, though he had no computer, realized it is like an operating system. It is always running in the background, taking care of things we need to function that we couldn’t possibly understand. Sometimes, glitches arise in the software that make things difficult for the user who is trying to complete tasks. People experiencing Conversion Disorder have no physiological basis for their physical symptoms. Keeping with the computer analogy, their experience may be thought of as, “their hardware is sound, but there is a glitch in the software.”
We’ve come a long way in understanding the brain and mind-body connection, but no clear brain activity has been identified as the culprit. Thus, it may well hold true that this is truly a mechanism of that intangible thing in our minds: the unconscious.
Conversion Disorder is also known as Functional Neurological Deficit Disorder (FNDD). This essentially means that the neurological hardware is intact, yet the patient exhibits symptoms of neurological deficit. One may also think of it as, despite showing symptoms of neurological deficits, it is serving a function, like expelling emotion or gaining attention. It is easiest to think of it as Conversion Disorder.
Conversion seems to happen in people who can’t, or won’t (such as men in the military), express strong emotions. As Freud conceptualized, strong emotional energy must somehow be discharged, so its “converted” to a physical symptom in order to be expressed. Given the nervous system has overlap with the mental, it makes sense they work in conjunction to do this. It is only diagnosed, according to the Diagnostic and Statistical Manual, 5th Edition (DSM-5) when medical and substance-related possibilities have been ruled out. Psychogenic Conversion symptoms include:
- Deficits in one of the five senses
- Seizures or syncope (fainting)
- Paralysis or significant weakness
- Parathesias (numbness, lack of sensation, or tingling)
- Loss of voluntary muscle control, often in the form of trouble swallowing, tremors or gait issues
- Speech problems
Another clue to their psychological roots are the sometimes strange manifestations of neurological symptoms. One of the strangest is “glove anesthesia” whereby a patient experiences lack of sensation of the hand to partway up the forearm, like a glove. Medically, this would never occur. Similarly, there is also “sock anesthesia.”
We know that Conversion is a psychological condition because it develops on the heels of very emotional situations. It is interesting that it has been noted to be more prominent in people who are uneducated (therefore less likely to have good problem-solving skills and be more prone to more emotional excessive stresses), in people who are traditionally less emotionally expressive (men, police, military), and has a tendency to be more prominent on the right side of the body (righties being more prevalent than lefties, the dominant side having the problem perhaps to be more significant).
Quick psychological intervention is correlated with better prognosis. What is more interesting, is that despite the havoc that being unable to hear, see, or walk may cause, many Conversion patients experience la belle indifference- they aren’t acutely bothered by it. Perhaps this is subconscious satisfaction that the emotional burdens are being cleared, or it is perceived as a positive thing given the distraction it is causing from the original stressor.
Nancy’s unconscious tapped into her past; she wanted her father more than anything right now, and an uncomfortable stomach used to be the ticket. However, as an adult, she knew better than to call him to come get her. Her emotions ran high, as if they couldn’t get expelled fast enough. Her parents, her future, and unresolved historical problems raced beneath the surface. Conveying her concerns to her advisor as she explained her performance downturn, Nancy’s head spun, and she fainted. It was as if she needed to remove herself from the conversation; it was too much. Her hearing continued to be problematic, as if she couldn’t bear to hear anymore bad news. It is no coincidence that patients’ conversion symptoms often have an uncanny parallel to what can’t be faced. Freud told us the type of conversion was likely symbolic to the situation that needed resolving.
British neurologist Suzanne O’Sullivan noted in her book Is It All In Your Head?, that it is important to understand that people with conversion symptoms are not faking for secondary gain. Their symptoms are very real, but have no underlying physical reason. Upon a hearing exam, someone like Nancy would perform poorly. If fainted, throwing water on her wouldn’t make her just “come to.” People whose conversion symptoms include parathesias don’t respond to pin pricks, and someone seizing won’t stop when people aren’t watching. Dr. O’Sullivan notes that researchers scanning brains of Conversion Disorder patients see a major difference compared to people who are acting and people who have actual neurological conditions.
Understandably, it is hard for patients to wrap their heads around this phenomenon, as they believe they’re being told they’re crazy or being accused of faking. It takes a special clinical skill, as noted in the New Therapist post How to Discuss Diagnosis with Psychotherapy Patients, for providers to successfully help a patient understand their diagnosis. Simply telling them they have no medical condition and therefore are being referred to psychotherapy won’t cut it. If they arrive for therapy, discussing how they are not alone in this, carefully and empathically educating them about the phenomenon, and that it is treatable, is of utmost importance if they are to engage in therapy.
The good news is, many respond well to treatment if an intervention occurs on the heels of the symptom onset. Given symptoms tend to develop when patients aren’t in touch with managing their emotions constructively, it makes sense that therapy focuses on doing just that. Not all Conversion Disorder patients are like Nancy with a Personality Disorder. However, with people like her, in the hands of a skilled Personality Disorder therapist, working on how they view the world, themselves, and how they interact with it, can also bring down the level of emotional intensity and keep future bouts at bay.
Nancy’s diagnoses would be Personality Disorder, Other (symptoms of Histrionic Personality Disorder; long-standing pattern of excessive emotionality, attention seeking behavior, and considers relationships more inmate than they actually are, in the absence of two other symptoms to make full diagnosis); and Conversion Disorder. It is important to note that she does not meet criteria for Somatic Symptom Disorder (a disorder marked by presence of significant psychological suffering from somatic symptoms not of a neurological nature, often also in the absence of medical basis, but not necessarily so) because her stomach upset does not lead to significant distress. Considering the excessive emotionality of those with Histrionic Personality Disorder, it isn’t unusual for them to develop comorbid Conversion Disorder. In another subconscious process, given Histrionic Personality patients thrive on attention, it is also likely that they come to realize the Conversion symptoms bring them attention, on which they thrive.
If a patient is prone to drama, that doesn’t mean we should ever be dismissive of their reports of neurological deficits or other somatic symptoms. It is important to suggest a physical evaluation, as it is indeed possible they have an actual underlying condition. It is equally important to know if underlying conditions are ruled out, as it will reconceptualize diagnosis and alter the course of treatment.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013
O’Sullivan, Suzanne. (2015). Is it all in your head?. Other Press