Psychosomatics 179Conversion disorders
Conversion disorders involve the presence of symptoms or deficits that
affect voluntary motor or sensory functioning; these symptoms or deficits
suggest an organic disorder but there is no evidence for organic causation
and there is positive evidence for psychological causation. These children
and adolescents usually present with a bizarre gait, weakness or paralysis
of the legs, funny turns or total incapacitation. Symptoms correspond
to the patient’s idea of what an illness should look like, only partially
matching a doctor’s idea; it is these discrepancies that often suggest that
the illness is ‘hysterical’.
The diagnosis of conversion disorders is fraught with difficulties. A
proportion of diagnosed children and adolescents do eventually turn out to
have an organic disease accounting for their symptoms. Apparently bizarre
symptoms may prove to be recognised features of a rare disorder that
the diagnosing doctor had never considered. Alternatively, the children
and adolescents may have an unusual presentation of a more common
disorder. To make matters even more complicated, organic factors may
still be important even if psychological factors are indeed responsible
for some symptoms. Children and adolescents whose physical symptoms
are not believed may then exaggerate the symptoms in order to be
taken seriously. In addition, children and adolescents may mimic their
own episodic disorders, so the fact that a child or adolescent sometimes
has ‘pseudoseizures’ does not rule out co-existent true epileptic seizures
as well.
Despite all these diagnostic pitfalls, most clinicians are convinced that
conversion disorder does exist. It can be seen as an (unconscious) enact-
ment of illness in response to an unbearable predicament. Some children
and adolescents respond to stress by acting tough, or grown-up, or pa-
thetic; others respond by acting ill. Doctors need to ensure that they do
not make these children and adolescents worse by initiating a protracted
series of investigations and second opinions; they also need to help affected
individuals find more adaptive ways of dealing with whatever stresses
precipitated the episode.
Conversion disorders are relatively rare in high-income countries, ac-
counting for roughly 1% of psychiatric in-patients – though the proportion
is probably higher among out-patients, particularly those referred by
paediatricians. These disorders are rare before the age of 5 and mostly
affect children and adolescents over the age of 10. Postpubertal girls may
be particularly susceptible. The rate of conversion disorders may be higher
in low- and middle-income countries.
The children and adolescents
Premorbid adjustment has often been normal; some have been particularly
perfectionist or conscientious students. Only a minority have another
psychiatric diagnosis in addition to the conversion disorder.