CONVERSION DISORDERS IN CHILDHOOD: A RETROSPECTIVE FOLLOW-UP STUDY OF 84 INPATIENTS C. Spierings P. J. E. Poels N. Sijben F. J. M . Gabreels W. 0. Renier
Paediatric neurologists are frequently asked to differentiate conversion disorders from diseases of the nervous system. Conversion hysteria has been an extensively studied psychiatric disorder since the time of Charcot, Freud and Breuer, but the literature provides only a few intensive studies of conversion reactions in childhood (Schneider and Rice 1979, Maloney 1980, Goodyer 1981, Volkmar et al. 1984, Siege1 and Barthel 1986, Aster et al. 1987, Lehmkuhl et al. 1989). DSM-111-R sets five criteria for the diagnosis of conversion disorder (300.11): (1) the patient presents with a predominant disturbance in physical functioning, suggesting a physical disorder; (2) after appropriate investigations the symptoms cannot be explained by a known physical disorder; (3) the symptoms are not under voluntary control; (4) psychological factors are thought to be involved; and ( 5 ) the symptoms are not limited to pain or disturbed sexual functioning. It is difficult to decide, however, what are the limits of ‘appropriate investigation’, i.e. how far one should go to exclude a physical disorder. In follow-up studies by Tissenbaum et al. (1951), Gatfield and Guze (1962), Slater and Glithero (1965) and Watson and Buranen (1979), between 13 and 46 per cent of patients were found
to have an organic basis for their presenting symptoms. In this study the records of neurological inpatients seen between 1977 and 1986 were reviewed and a follow-up study of 84 patients with the diagnosis of conversion disorder was conducted to answer the following questions: (1) Which aspects of the medical and family histories are important in diagnosing conversion disorder? (2) Is there any evidence of the so-called ‘point of minor resistance’ in conversion disorder? (3) Are there distinguishable sex-specific symptoms in conversion disorder in childhood? (4) What is the validity of the diagnosis of conversion disorder at follow-up?
00 P ‘A
00 W
mm
Method The final diagnoses of all inpatients discharged from the child neurology department between 1977 and 1986 (N = 3100) were screened independently by the first two authors. Patients with diagnoses of hysterical neurosis, conversion hysteria or conversion disorder were included in the study. Patients were excluded if they were younger than five years or if their last admission to the child neurology department was less than one year prior to
865
TABLE I Main signs and symptoms in relation to gender
0
&
Group
I I1 111 1v V
rri 5
a;
Main symptoms and presenting signs Paresis, paralysis, gait disorder, tics Pain syndromes, paraesthesia, anaesthesia Anosmia, deafness, visual disturbances Fits, ‘hystero-epilepsy’, loss of consciousness Conductive disorders with somatization
Female
(N= 26)
7
5
21
12
4
0
18
I
8
2
the patient’s present state of health, present complaints and any subsequent organic illness and therapy.
TABLE I1 Significant data from medical histories Hospital admission for observation or surgical intervention
29
Outpatient clinic care or intervention
8
Under care of general practitioner
15
52 (62%)
.-c 0 v)
u
c
6
866
Male
(N= 58)
screning. They were also excluded if their complaints or symptoms were functional, occurred incidentally or had no relation to wider somatization. The final sample consisted of 84 patients. Selection was in accordance with DSM-111-R criteria, with one exception: when psychogenic pain as the predominant symptom was associated with conversion symptomatology, it was diagnosed as conversion disorder and those children were included in the sample. The distinction between conversion and psychogenic pain disorder was considered to be rather arbitrary. The 84 case records were reviewed for basic demographic information, medical history, family history, developmental data, and results of physical examinations and technical investigations. The charts were also reviewed for information about referrals to other medical specialists, paramedical tests and possible aetiological factors, and also for information about the period after discharge. The follow-up study was carried out by means of a questionnaire enquiring about
Results The patients’ ages ranged from six to 17 years, with a mean of 12-1 years. The fema1e:male ratio was 2.2: 1, but below the age of 10 the ratio was almost equal. The patients were grouped under five headings, according to the main symptom (Table I). There were 12 patients with motor dysfunctions, 33 with sensory disorders, including unexplained pain syndromes, four with dysfunction of sensory organs, 25 with hysterical fits and autonomic vegetative symptoms, and 10 with conductive disorders combined with severe somatization. Headache, dizziness and sleeping difficulties were frequently reported as associated complaints in all five groups. General practitioners had referred 40 per cent of the patients for neurological evaluation and 60 per cent had already been referred to one or more medical specialists before admission. The children’s educational level, judged from the type of school they attended, was comparable to the distribution in the general population. Their developmental histories showed no exceptional features. The medical histories of the patients showed that, apart from common childhood diseases, including adenoidectomy and tonsillectomy, 62 per cent had had an organic illness requiring one or more hospital admission for observation or surgical intervention (Table 11). At least
30 per cent had consulted a doctor previously because of other unexplained symptoms, but patients were not consistently questioned about these symptoms. A person with emotional significance for the patient, serving as a model for the symptoms, was identified for 29 per cent of the children. The phenomenon ‘la belle indifference’ was noted in 8 per cent. The medical histories of significant family members showed organic disorders in 45 per cent, psychosomatic diseases in 44 per cent and psychiatric disorders in 26 per cent. All patients had undergone physical examination and laboratory investigations of blood, urine and faeces, which yielded no abnormality. Cerebrospinal fluid examination and neuroradiological studies were normal. The results of special studies performed for specific indications were normal. Neurophysiological studies consisted of EMG, Doppler and evoked potentials, which were all normal. Almost all of the children had had an EEG (Table 111). A variety of slight to moderate EEG disturbances such as regulatory instability, diffuse irritability or immature differentiation was observed in 51 per cent of the children, but had no relation to the main symptom of the conversion disorder: these EEG disturbances were equally distributed over the five groups of patients (Table IV). Before admission, 7 per cent had consulted a psychiatrist. During admission, 87 per cent had been observed by a psychiatrist, psychologist, social or educational worker. For the remaining 6 per cent, no special attention had been paid to psychosocial factors. For 88 per cent of the children a psychogenic aetiology became evident; in most cases during their stay in the neurological department, but in some cases at first consultation. Special attention was given to three types of somatic factors that might be considered points of minor resistance: a pre-existing bodily defect, a preceding trauma and EEG disturbances. In the past, four patients (5 per cent) had been treated for bodily defects, namely malformation of the spine, an atrophic arm, deformity of both knees and
TABLE 111
Technical investigations performed during admission Laboratory investigations Blood, urine and faeces Cerebrospinal fluid
82 69
Neuroradiological studies CT scan Invasive radiological studies
79 30
Neurophysiological studies EEG Evoked potentials, EMG, HTG
80 32
TABLE IV
Distribution of patients with EEG disturbances Patient group according to main symptom I* I1 111
IV V
Total
All patients N %
12 33 4 25 10 84
14 39 5 30 12 100
Patients with EEG disturbances N %
5 19 1 16 6 47
11 40 2 34 13 100
*See Table I for details of groups.
hypermetropic eyes. These patients’ conversion symptoms were superimposed on the primary disorder. In 17 per cent of the children the conversion disorder was preceded by an accident, but the presenting symptoms could not be explained by this trauma. In all but one of these patients the conversion reaction seized upon the site of the body that had been injured, e.g. hypaesthesia of the left arm a few months after injury to this limb. In 11 of 14 patients with a preceding trauma the main symptom was a sensory disorder.
study The follow-up questionnaire developed for this study contained items about the patients’ present state of health, their present symptoms, and any further treatment during the follow-up period. Follow-up periods ranged from 13 to 131 months, with a mean of 50.7 months. This questionnaire was sent to the patients’ parents, and 82 per cent returned FOllOW-Up
867
0
P
z
8 u,
ti m 0
E
.-s!
n E:
.-mL
> 0
u
the form. 6 per cent described the condition of the child as bad, and 22 per cent reported no improvement, but in the majority of cases (72 per cent) improvement of the condition was reported. Despite these positive answers, however, 54 per cent of the children still had complaints: 33 per cent had the same complaints as before, 17 per cent had developed other symptoms and 4 per cent had both ‘old’ and ‘new’ complaints. Information about therapy after discharge was obtained from two sources: data available in the records and data in the returned questionnaires. By combining this information, we obtained the following picture: 20 per cent had received therapy from a physician, 29 per cent had had mental health care, 8 per cent received physical therapy, 2 per cent went to alternative medical services for the same symptoms and 15 per cent reported new symptoms to a physician. 40 per cent underwent no further treatment. There is overlap between these groups because some patients had had both somatic and psychiatric treatment, while others retained the same symptoms but developed new ones as well. After discharge, five patients had been diagnosed differently: for four children originally diagnosed as ‘hystero-epileptic’ the diagnosis had been changed to epilepsy and successful treatment with carbamazepine was started; and one patient with conversive backache partly recovered during psychotherapy, but at the time of follow-up she was diagnosed as having a pancreatic cyst.
Discussion
868
The absence of a control group, a limitation of this and some other studies of conversion disorder, makes some findings difficult to interpret. However, the results of the present study are similar in a number of respects to those in other studies. The mean age of the patients and the fema1e:male ratio are of the same order as reported by Maloney (1980), Goodyer (1981), Volkmar et al. (1984), Siegel and Barthel(l986) and von Aster et al. (1987). Like Schneider and Rice (1979), we found an approximately equal sex distribution of cases below the age of
10, with an increase in the number of girls in the pubescent and postpubertal period. Perhaps pubescent boys consider that hysterical traits are not consistent with their male identity, so have to solve their intrapsychic conflicts in a different way. Maloney reported some sex differences (more females presenting with syncope and headache; more males with paralysis and pseudoseizures) but in the present study no sex-specific symptoms were found. The method of investigation of Lehmkuhl et al. (1989) is quite similar to that in our study and several of their results are in agreement with our findings. One difference is the higher number of neurological abnormalities (14 per cent) in their study (none in our population), which could be explained by the fact that their study was carried out in a psychiatric department and ours in a neurological unit. Another important difference is the high percentage of our patients with a history of organic illnesses. ‘La belle indifference’ was the exception rather than the rule in our sample. In other reports there is such wide variation in the frequency of this finding (Goodyer 1981, Volkmar et al. 1984, Siegel and Barthel 1986) that the importance of this clinical feature must be doubted. Two findings in the present study are of particular interest: the existence of a history of organic illness in the patients and their families, and the r61e of a point of minor resistance. Goodyer (1981), Volkmar et al. (1984) and Siegel and Barthel (1986) reported a history of organic illness in the patients and their families ranging from 27 to 40 per cent. In our study, 62 per cent of the patients and 45 per cent of family members had a history of significant organic diseases. The present study provides evidence that a point of minor resistance can play a r81e in conversion disorders. In the patients who viewed a part of their body as a weak spot because of a pre-existing bodily defect, the conversion symptom occurred in that part of the body. In all except one of the cases with preceding trauma, the conversion symptom was located in the affected part of the body. Additionally, in most cases the chief
symptom was the same one, namely a sensory disorder. On the other hand, there proved to be no relationship between the point of minor resistance and the chief conversion symptom in patients who had an EEG disturbance but were not aware of it. However, although EEG disturbances were observed in 51 per cent of this sample, they were non-specific and mostly only slight, so we cannot be conclusive about these findings. Both findings-a burdensome medical history and a part of the body experienced as a point of minor resistance-support the aetiological theory of learned behaviour in relation to conversion disorder (Dubowitz and Hersov 1976, Goodyer 1981, Ford and Folks 1985). Previous experience will have taught the child that physical disability is a way of dealing with emotional distress, and repeated investigations will have reinforced this ‘learned maladaptive behaviour’. A point of minor resistance is the ground on which this learned behaviour can be displayed. A personal model for the symptoms, present in 29 per cent of cases, also suggests a learning process in the production of the syndrome. This has also been proposed by Volkmar et al. and Siegel and Barthel; they report a model for the symptom in 50 and 66 per cent, respectively. The presence or absence of a personal model was not consistently recorded in the charts of our patients, which may explain the lower incidence in our study. Two of our results differ significantly from those reported in the literature: the validity of the diagnosis and a history of psychiatric treatment for the patients or their family members. The proportion of valid diagnoses in our study is much higher than that reported in other followup studies: Tissenbaum et al. (1951), Gatfield and Guze (1962), Slater and Glithero (1965) and Watson and Buranen (1979) reported proportions of 13 to 46 per cent. Only five of our patients received an organic diagnosis during the follow-up period, and there is no evidence that these somatic diagnoses could have been determined during these patients’ admission. Fewer of our patients (7 per cent) and their family members (26 per
cent) had a history of psychiatric treatment than in the reports of Maloney (1980), Goodyer (1981), Volkmar et al. (1984) and Siegel and Barthel (1986), in which the proportions ranged from 44 to 80 per cent. These different findings may be explained by the fact that the present study was carried out in a neurological department, where first of all an organic disease had to be excluded. The somatic examination is very extensive because we think all patients with symptoms of conversion disorder should have a relatively complete medical check-up. Like Goodyer (1981), we also plead for early psychiatric intervention. Before admission, our patients or their parents had sought a somatic solution for their complaints, and during the admission they continued to insist on a somatic approach rather than a psychiatric one. During the follow-up period, 44 per cent were still seeking somatic help. In our opinion this explains both the high degree of validity of diagnosis and the low incidence of a history of psychiatric treatment. The question is whether these extensive investigations can be replaced by screening tests in order to avoid the emotional and financial costs of somatic examinations. Dubowitz and Hersov (1976) point out that unnecessary, and often painful, invasive investigation can result in reinforcement and fixation of the symptoms. It would be wrong, however, to suggest that all somatic investigations are unnecessary; the important question is whether the diagnosis could have been achieved in a less expensive way, using methods such as a programme evaluation (Sijben 1986). Adequate registration of the symptoms, the previous history and the results of investigations, etc., are essential prerequisites for such a project. Whenever clinicians presume or suspect a conversion disorder, they should enquire about previous unexplained symptoms, preceding trauma, and the presence of a model for the symptoms. It needs emphasising, too, that a medical history of serious organic illness does not exclude a diagnosis of conversion disorder.
-
I I
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ri” rn
2 3 ‘D
B
869
Accepted for publication 6th February 1990.
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Authors’ Appointments C. Spierings, M.D.; *P. J. E. Poels. M.D.: F. J. M. Gabreels, M.D., Ph.D.; W. 0. Renier, M.D., Ph.D.;
Institute of Neurology, St. Radboud Hospital, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. N. Sijben, M.D., Ph.D., Institute of Psychiatry, St. Radboud Hospital.
*Correspondence to second author.
SUMMARY The medical histories of 84 children who had been diagnosed as having conversion disorder were reviewed in a follow-up study, and the validity of this diagnosis was examined. The fema1e:male ratio was 2.1:1, although below the age of 10 the ratio was almost equal. The medical histories of 62 per cent of the patients showed an organic illness, and 5 1 per cent had various slight to moderate EEG disturbances. The validity of the diagnosis was very high: only five were found to have organic disease during the follow-up period. Children with symptoms of conversion disorder should receive appropriate medical investigations, but the authors question whether extensive investigations could not be replaced by screening tests, combined with early psychiatric intervention. RESUME Les troubles d’hysterie de conversion durant I’enfance Les histoires medicales de 84 enfants chez qui avait ete diagnostique un trouble de conversion ont CtC revues au cows d’une etude longitudinale et la validite du diagnostic precisee. Le rapport garCon/fille Ctait de 2,2/1 bien qu’au dessous de 10 ans, le nombre de filles et de garcons etait presque Cgal. Les histoires medicales de 62 pour cent des patients revelaient une affection organique et on notait dans 5 1 pour cent des cas, des perturbations EEG variees, lkgeres a moderees. La validite du diagnostic etait tres 6levCe:une affection organique n’apparut durant le suivi que dans cinq cas. Les enfants presentant des troubles de conversion devraient beneficier d’investigations medicales appropriees mais les auteurs se demandent si les investigations coDteuses ne pourraient pas Stre remplacees par des tests de dkpistage, associes a une intervention psychiatrique precoce.
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ZUSAMMENFASSUNG Con versionserkrankungen im Kindesalter Im Rahmen einer Kontrollstudie wurden die Krankenakten von 84 Kindern mit einer Conversionserkrankung durchgesehen und es wurde die Validitat der Diagnose iiberpriift. Das Verhaltnis weib1ich:mannlich betrug 2.2: 1, unter 10 Jahren gab es allerdings etwa gleichviele Madchen wie Jungen. Bei 62 Prozent der Patienten fand sich in der Anamnese eine organische Erkrankung und 5 1 Prozent hatten unterschiedliche leichte bis mittelschwere EEG-Veranderungen. Die Validitat der Diagnose war sehr hoch: wahrend der Kontrollperiode wurde bei nur fiinf Patienten eine organische Erkrankung gefunden. Kinder mit den Symptomen einer Conversionserkrankung sollten medizinisch gut untersucht werden, aber die Autoren stellen die Frage, ob nicht die extensiven Untersuchungen durch Screening Tests, verbunden mit friihzeitiger psychiatrischer Betreuung, ersetzt werden konnten. RESUMEN Alteraciones de conversion en la infancia Las historias medicas de 84 niflos diagnosticados de alteraciones de conversion fueron revisadas en un estudio de curso y se examino la validez del diagnostico. La relacion hembraharon fue de 2.2:l aunque por debajo de 10s diez aflos el numero de niflos y niflas era casi igual. Las historias clinicas del 62 por ciento de 10s pacientes mostraron una enfermedad organica y en el 5 1 por ciento varias alteraciones EEG de ligeras a moderadas. La validez del diagnostico era aka: solo cinco casos mostraron tener una enfermedad organica durante el period0 de seguimiento. Los niflos con sintomas de alteraciones de conversion deberian recibir investigaciones medicas apropriadas, pero 10s autores se preguntan si unas investigaciones extensas no podrian ser reemplzadas por tests de barrido en combinacion con una intervention psiquihtrica.
870
References American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders, DSM-III; Washington, DC- American Psychiatric Association. Aster, M. von, Pfeiffer, E., Gobel, D., Steinhausen, H.Ch. (1987) ‘Konversions-syndromebei Kindern und Jugendlichen.’ Praxis der Kinderpsychologie und Kinderpsychiatrie, 36, 240-248. Dubowitz, V., Hersov, L. (1976) ‘Management of children with non-organic (hysterical) disorders of motor function.’ Developmental Medicine and Child Neurology, 18, 358-368. Ford, C. V., Folks, D. G. (1985) ‘Conversion
disorders: an overview.’ Psychosomatics, 26, 371-383. Gatfield, P. D., Guze, S. B. (1962) ‘Prognosis and differential diagnosis of conversion reactions: a follow-up study.’ Diseases of the Nervous System, 23, 623-63 1 . Goodyer, I. (1981) ‘Hysterical conversion reactions in childhood.’ Journal of Child Psychology and Psychiatry, 22, 179-188. Lehmkuhl, G., Blanz, B., Lehmkuhl, U., BraunScharm, H. (1989) ‘Conversion disorder (DSM-111 300.11): symptomatology and course in childhood and adolescence.’ European Archives
of Psychiatry and Neurological Sciences, 238, 155-160.
Maloney, M. J. (1980) ‘Diagnosing hysterical conversion reactions in children.’ Journal of Pediatrics, 97, 1016-1020. Schneider, S., Rice, D. R. (1979) ‘Neurologic manifestations of childhood hysteria.’ Journal of Pediatrics, 94, 153-156. Siegel, M., Barthel, R. P. (1986) ‘Conversion disorders on a child psychiatry consultation service.’ Psychosomatics, 27, 201-204. Sijben, A. E. S. (1986) Omzien naar Weldoen; Programma-Evaluatie in Theorie en Praktijk. University of Nijmegen, Netherlands. Slater, E. T. O., Glithero, E. (1965) ‘A follow-up
of patients diagnosed as suffering from “hysteria” ’. Journal of Psychosomatic Research,
9, 9-13.
Tissenbaum, M. J . , Harter, H. M., Friedman, A. P. (1951) ‘Organic neurological syndromes diagnosed as functional disorders.’ Journal of the American Medical Association, 147, 1519-1521. Volkmar, F. R., Poll, J., Lewis, M . (1984) ‘Conversion reactions in childhood and adolescence.’ Journal of the American Academy of Child Psychiatry, 23, 424-430. Watson, C. G., Buranen, C. (1979) ‘The frequency and identification of false positive conversion reactions.’ Journal of Nervous and Mental Disease, 167, 243-247.
0”
5
8 71
Paediatric neurologists are frequently asked to differentiate conversion disorders from diseases of the nervous system. Conversion hysteria has been an extensively studied psychiatric disorder since the time of Charcot, Freud and Breuer, but the literature provides only a few intensive studies of conversion reactions in childhood (Schneider and Rice 1979, Maloney 1980, Goodyer 1981, Volkmar et al. 1984, Siege1 and Barthel 1986, Aster et al. 1987, Lehmkuhl et al. 1989). DSM-111-R sets five criteria for the diagnosis of conversion disorder (300.11): (1) the patient presents with a predominant disturbance in physical functioning, suggesting a physical disorder; (2) after appropriate investigations the symptoms cannot be explained by a known physical disorder; (3) the symptoms are not under voluntary control; (4) psychological factors are thought to be involved; and ( 5 ) the symptoms are not limited to pain or disturbed sexual functioning. It is difficult to decide, however, what are the limits of ‘appropriate investigation’, i.e. how far one should go to exclude a physical disorder. In follow-up studies by Tissenbaum et al. (1951), Gatfield and Guze (1962), Slater and Glithero (1965) and Watson and Buranen (1979), between 13 and 46 per cent of patients were found
to have an organic basis for their presenting symptoms. In this study the records of neurological inpatients seen between 1977 and 1986 were reviewed and a follow-up study of 84 patients with the diagnosis of conversion disorder was conducted to answer the following questions: (1) Which aspects of the medical and family histories are important in diagnosing conversion disorder? (2) Is there any evidence of the so-called ‘point of minor resistance’ in conversion disorder? (3) Are there distinguishable sex-specific symptoms in conversion disorder in childhood? (4) What is the validity of the diagnosis of conversion disorder at follow-up?
00 P ‘A
00 W
mm
Method The final diagnoses of all inpatients discharged from the child neurology department between 1977 and 1986 (N = 3100) were screened independently by the first two authors. Patients with diagnoses of hysterical neurosis, conversion hysteria or conversion disorder were included in the study. Patients were excluded if they were younger than five years or if their last admission to the child neurology department was less than one year prior to
865
TABLE I Main signs and symptoms in relation to gender
0
&
Group
I I1 111 1v V
rri 5
a;
Main symptoms and presenting signs Paresis, paralysis, gait disorder, tics Pain syndromes, paraesthesia, anaesthesia Anosmia, deafness, visual disturbances Fits, ‘hystero-epilepsy’, loss of consciousness Conductive disorders with somatization
Female
(N= 26)
7
5
21
12
4
0
18
I
8
2
the patient’s present state of health, present complaints and any subsequent organic illness and therapy.
TABLE I1 Significant data from medical histories Hospital admission for observation or surgical intervention
29
Outpatient clinic care or intervention
8
Under care of general practitioner
15
52 (62%)
.-c 0 v)
u
c
6
866
Male
(N= 58)
screning. They were also excluded if their complaints or symptoms were functional, occurred incidentally or had no relation to wider somatization. The final sample consisted of 84 patients. Selection was in accordance with DSM-111-R criteria, with one exception: when psychogenic pain as the predominant symptom was associated with conversion symptomatology, it was diagnosed as conversion disorder and those children were included in the sample. The distinction between conversion and psychogenic pain disorder was considered to be rather arbitrary. The 84 case records were reviewed for basic demographic information, medical history, family history, developmental data, and results of physical examinations and technical investigations. The charts were also reviewed for information about referrals to other medical specialists, paramedical tests and possible aetiological factors, and also for information about the period after discharge. The follow-up study was carried out by means of a questionnaire enquiring about
Results The patients’ ages ranged from six to 17 years, with a mean of 12-1 years. The fema1e:male ratio was 2.2: 1, but below the age of 10 the ratio was almost equal. The patients were grouped under five headings, according to the main symptom (Table I). There were 12 patients with motor dysfunctions, 33 with sensory disorders, including unexplained pain syndromes, four with dysfunction of sensory organs, 25 with hysterical fits and autonomic vegetative symptoms, and 10 with conductive disorders combined with severe somatization. Headache, dizziness and sleeping difficulties were frequently reported as associated complaints in all five groups. General practitioners had referred 40 per cent of the patients for neurological evaluation and 60 per cent had already been referred to one or more medical specialists before admission. The children’s educational level, judged from the type of school they attended, was comparable to the distribution in the general population. Their developmental histories showed no exceptional features. The medical histories of the patients showed that, apart from common childhood diseases, including adenoidectomy and tonsillectomy, 62 per cent had had an organic illness requiring one or more hospital admission for observation or surgical intervention (Table 11). At least
30 per cent had consulted a doctor previously because of other unexplained symptoms, but patients were not consistently questioned about these symptoms. A person with emotional significance for the patient, serving as a model for the symptoms, was identified for 29 per cent of the children. The phenomenon ‘la belle indifference’ was noted in 8 per cent. The medical histories of significant family members showed organic disorders in 45 per cent, psychosomatic diseases in 44 per cent and psychiatric disorders in 26 per cent. All patients had undergone physical examination and laboratory investigations of blood, urine and faeces, which yielded no abnormality. Cerebrospinal fluid examination and neuroradiological studies were normal. The results of special studies performed for specific indications were normal. Neurophysiological studies consisted of EMG, Doppler and evoked potentials, which were all normal. Almost all of the children had had an EEG (Table 111). A variety of slight to moderate EEG disturbances such as regulatory instability, diffuse irritability or immature differentiation was observed in 51 per cent of the children, but had no relation to the main symptom of the conversion disorder: these EEG disturbances were equally distributed over the five groups of patients (Table IV). Before admission, 7 per cent had consulted a psychiatrist. During admission, 87 per cent had been observed by a psychiatrist, psychologist, social or educational worker. For the remaining 6 per cent, no special attention had been paid to psychosocial factors. For 88 per cent of the children a psychogenic aetiology became evident; in most cases during their stay in the neurological department, but in some cases at first consultation. Special attention was given to three types of somatic factors that might be considered points of minor resistance: a pre-existing bodily defect, a preceding trauma and EEG disturbances. In the past, four patients (5 per cent) had been treated for bodily defects, namely malformation of the spine, an atrophic arm, deformity of both knees and
TABLE 111
Technical investigations performed during admission Laboratory investigations Blood, urine and faeces Cerebrospinal fluid
82 69
Neuroradiological studies CT scan Invasive radiological studies
79 30
Neurophysiological studies EEG Evoked potentials, EMG, HTG
80 32
TABLE IV
Distribution of patients with EEG disturbances Patient group according to main symptom I* I1 111
IV V
Total
All patients N %
12 33 4 25 10 84
14 39 5 30 12 100
Patients with EEG disturbances N %
5 19 1 16 6 47
11 40 2 34 13 100
*See Table I for details of groups.
hypermetropic eyes. These patients’ conversion symptoms were superimposed on the primary disorder. In 17 per cent of the children the conversion disorder was preceded by an accident, but the presenting symptoms could not be explained by this trauma. In all but one of these patients the conversion reaction seized upon the site of the body that had been injured, e.g. hypaesthesia of the left arm a few months after injury to this limb. In 11 of 14 patients with a preceding trauma the main symptom was a sensory disorder.
study The follow-up questionnaire developed for this study contained items about the patients’ present state of health, their present symptoms, and any further treatment during the follow-up period. Follow-up periods ranged from 13 to 131 months, with a mean of 50.7 months. This questionnaire was sent to the patients’ parents, and 82 per cent returned FOllOW-Up
867
0
P
z
8 u,
ti m 0
E
.-s!
n E:
.-mL
> 0
u
the form. 6 per cent described the condition of the child as bad, and 22 per cent reported no improvement, but in the majority of cases (72 per cent) improvement of the condition was reported. Despite these positive answers, however, 54 per cent of the children still had complaints: 33 per cent had the same complaints as before, 17 per cent had developed other symptoms and 4 per cent had both ‘old’ and ‘new’ complaints. Information about therapy after discharge was obtained from two sources: data available in the records and data in the returned questionnaires. By combining this information, we obtained the following picture: 20 per cent had received therapy from a physician, 29 per cent had had mental health care, 8 per cent received physical therapy, 2 per cent went to alternative medical services for the same symptoms and 15 per cent reported new symptoms to a physician. 40 per cent underwent no further treatment. There is overlap between these groups because some patients had had both somatic and psychiatric treatment, while others retained the same symptoms but developed new ones as well. After discharge, five patients had been diagnosed differently: for four children originally diagnosed as ‘hystero-epileptic’ the diagnosis had been changed to epilepsy and successful treatment with carbamazepine was started; and one patient with conversive backache partly recovered during psychotherapy, but at the time of follow-up she was diagnosed as having a pancreatic cyst.
Discussion
868
The absence of a control group, a limitation of this and some other studies of conversion disorder, makes some findings difficult to interpret. However, the results of the present study are similar in a number of respects to those in other studies. The mean age of the patients and the fema1e:male ratio are of the same order as reported by Maloney (1980), Goodyer (1981), Volkmar et al. (1984), Siegel and Barthel(l986) and von Aster et al. (1987). Like Schneider and Rice (1979), we found an approximately equal sex distribution of cases below the age of
10, with an increase in the number of girls in the pubescent and postpubertal period. Perhaps pubescent boys consider that hysterical traits are not consistent with their male identity, so have to solve their intrapsychic conflicts in a different way. Maloney reported some sex differences (more females presenting with syncope and headache; more males with paralysis and pseudoseizures) but in the present study no sex-specific symptoms were found. The method of investigation of Lehmkuhl et al. (1989) is quite similar to that in our study and several of their results are in agreement with our findings. One difference is the higher number of neurological abnormalities (14 per cent) in their study (none in our population), which could be explained by the fact that their study was carried out in a psychiatric department and ours in a neurological unit. Another important difference is the high percentage of our patients with a history of organic illnesses. ‘La belle indifference’ was the exception rather than the rule in our sample. In other reports there is such wide variation in the frequency of this finding (Goodyer 1981, Volkmar et al. 1984, Siegel and Barthel 1986) that the importance of this clinical feature must be doubted. Two findings in the present study are of particular interest: the existence of a history of organic illness in the patients and their families, and the r61e of a point of minor resistance. Goodyer (1981), Volkmar et al. (1984) and Siegel and Barthel (1986) reported a history of organic illness in the patients and their families ranging from 27 to 40 per cent. In our study, 62 per cent of the patients and 45 per cent of family members had a history of significant organic diseases. The present study provides evidence that a point of minor resistance can play a r81e in conversion disorders. In the patients who viewed a part of their body as a weak spot because of a pre-existing bodily defect, the conversion symptom occurred in that part of the body. In all except one of the cases with preceding trauma, the conversion symptom was located in the affected part of the body. Additionally, in most cases the chief
symptom was the same one, namely a sensory disorder. On the other hand, there proved to be no relationship between the point of minor resistance and the chief conversion symptom in patients who had an EEG disturbance but were not aware of it. However, although EEG disturbances were observed in 51 per cent of this sample, they were non-specific and mostly only slight, so we cannot be conclusive about these findings. Both findings-a burdensome medical history and a part of the body experienced as a point of minor resistance-support the aetiological theory of learned behaviour in relation to conversion disorder (Dubowitz and Hersov 1976, Goodyer 1981, Ford and Folks 1985). Previous experience will have taught the child that physical disability is a way of dealing with emotional distress, and repeated investigations will have reinforced this ‘learned maladaptive behaviour’. A point of minor resistance is the ground on which this learned behaviour can be displayed. A personal model for the symptoms, present in 29 per cent of cases, also suggests a learning process in the production of the syndrome. This has also been proposed by Volkmar et al. and Siegel and Barthel; they report a model for the symptom in 50 and 66 per cent, respectively. The presence or absence of a personal model was not consistently recorded in the charts of our patients, which may explain the lower incidence in our study. Two of our results differ significantly from those reported in the literature: the validity of the diagnosis and a history of psychiatric treatment for the patients or their family members. The proportion of valid diagnoses in our study is much higher than that reported in other followup studies: Tissenbaum et al. (1951), Gatfield and Guze (1962), Slater and Glithero (1965) and Watson and Buranen (1979) reported proportions of 13 to 46 per cent. Only five of our patients received an organic diagnosis during the follow-up period, and there is no evidence that these somatic diagnoses could have been determined during these patients’ admission. Fewer of our patients (7 per cent) and their family members (26 per
cent) had a history of psychiatric treatment than in the reports of Maloney (1980), Goodyer (1981), Volkmar et al. (1984) and Siegel and Barthel (1986), in which the proportions ranged from 44 to 80 per cent. These different findings may be explained by the fact that the present study was carried out in a neurological department, where first of all an organic disease had to be excluded. The somatic examination is very extensive because we think all patients with symptoms of conversion disorder should have a relatively complete medical check-up. Like Goodyer (1981), we also plead for early psychiatric intervention. Before admission, our patients or their parents had sought a somatic solution for their complaints, and during the admission they continued to insist on a somatic approach rather than a psychiatric one. During the follow-up period, 44 per cent were still seeking somatic help. In our opinion this explains both the high degree of validity of diagnosis and the low incidence of a history of psychiatric treatment. The question is whether these extensive investigations can be replaced by screening tests in order to avoid the emotional and financial costs of somatic examinations. Dubowitz and Hersov (1976) point out that unnecessary, and often painful, invasive investigation can result in reinforcement and fixation of the symptoms. It would be wrong, however, to suggest that all somatic investigations are unnecessary; the important question is whether the diagnosis could have been achieved in a less expensive way, using methods such as a programme evaluation (Sijben 1986). Adequate registration of the symptoms, the previous history and the results of investigations, etc., are essential prerequisites for such a project. Whenever clinicians presume or suspect a conversion disorder, they should enquire about previous unexplained symptoms, preceding trauma, and the presence of a model for the symptoms. It needs emphasising, too, that a medical history of serious organic illness does not exclude a diagnosis of conversion disorder.
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Accepted for publication 6th February 1990.
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Authors’ Appointments C. Spierings, M.D.; *P. J. E. Poels. M.D.: F. J. M. Gabreels, M.D., Ph.D.; W. 0. Renier, M.D., Ph.D.;
Institute of Neurology, St. Radboud Hospital, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. N. Sijben, M.D., Ph.D., Institute of Psychiatry, St. Radboud Hospital.
*Correspondence to second author.
SUMMARY The medical histories of 84 children who had been diagnosed as having conversion disorder were reviewed in a follow-up study, and the validity of this diagnosis was examined. The fema1e:male ratio was 2.1:1, although below the age of 10 the ratio was almost equal. The medical histories of 62 per cent of the patients showed an organic illness, and 5 1 per cent had various slight to moderate EEG disturbances. The validity of the diagnosis was very high: only five were found to have organic disease during the follow-up period. Children with symptoms of conversion disorder should receive appropriate medical investigations, but the authors question whether extensive investigations could not be replaced by screening tests, combined with early psychiatric intervention. RESUME Les troubles d’hysterie de conversion durant I’enfance Les histoires medicales de 84 enfants chez qui avait ete diagnostique un trouble de conversion ont CtC revues au cows d’une etude longitudinale et la validite du diagnostic precisee. Le rapport garCon/fille Ctait de 2,2/1 bien qu’au dessous de 10 ans, le nombre de filles et de garcons etait presque Cgal. Les histoires medicales de 62 pour cent des patients revelaient une affection organique et on notait dans 5 1 pour cent des cas, des perturbations EEG variees, lkgeres a moderees. La validite du diagnostic etait tres 6levCe:une affection organique n’apparut durant le suivi que dans cinq cas. Les enfants presentant des troubles de conversion devraient beneficier d’investigations medicales appropriees mais les auteurs se demandent si les investigations coDteuses ne pourraient pas Stre remplacees par des tests de dkpistage, associes a une intervention psychiatrique precoce.
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ZUSAMMENFASSUNG Con versionserkrankungen im Kindesalter Im Rahmen einer Kontrollstudie wurden die Krankenakten von 84 Kindern mit einer Conversionserkrankung durchgesehen und es wurde die Validitat der Diagnose iiberpriift. Das Verhaltnis weib1ich:mannlich betrug 2.2: 1, unter 10 Jahren gab es allerdings etwa gleichviele Madchen wie Jungen. Bei 62 Prozent der Patienten fand sich in der Anamnese eine organische Erkrankung und 5 1 Prozent hatten unterschiedliche leichte bis mittelschwere EEG-Veranderungen. Die Validitat der Diagnose war sehr hoch: wahrend der Kontrollperiode wurde bei nur fiinf Patienten eine organische Erkrankung gefunden. Kinder mit den Symptomen einer Conversionserkrankung sollten medizinisch gut untersucht werden, aber die Autoren stellen die Frage, ob nicht die extensiven Untersuchungen durch Screening Tests, verbunden mit friihzeitiger psychiatrischer Betreuung, ersetzt werden konnten. RESUMEN Alteraciones de conversion en la infancia Las historias medicas de 84 niflos diagnosticados de alteraciones de conversion fueron revisadas en un estudio de curso y se examino la validez del diagnostico. La relacion hembraharon fue de 2.2:l aunque por debajo de 10s diez aflos el numero de niflos y niflas era casi igual. Las historias clinicas del 62 por ciento de 10s pacientes mostraron una enfermedad organica y en el 5 1 por ciento varias alteraciones EEG de ligeras a moderadas. La validez del diagnostico era aka: solo cinco casos mostraron tener una enfermedad organica durante el period0 de seguimiento. Los niflos con sintomas de alteraciones de conversion deberian recibir investigaciones medicas apropriadas, pero 10s autores se preguntan si unas investigaciones extensas no podrian ser reemplzadas por tests de barrido en combinacion con una intervention psiquihtrica.
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