PSYCHIATRY
Conversion
Hysteria A Case
in Childhood
Report and
a
Reminder
Alayne Yates, M.D.,* Margaret Steward,
Ph.D.**
’ ’
i i1 1YSTERIA&dquo; //
is
derived
by Hippocrates &dquo;Hysteron,&dquo; meaning uterus. Hippocrates thought that the condition resulted from the migration of the uterus in widows and spinsters. An exclusively physical cause continued to be presumed until Mills wrote in 1890 that &dquo;hysteria in children a
term
from the Greek
has therefore no morbid anatomy that can be discriminated either by scalpel or microscope... and the psychical element must enter into the explanation of nearly all cases.&dquo;’ Interest in this condition reached new heights in the late 19th century with
dramatic cures by the use of hypnosis. Freud 2-4 employed his painstaking analysis of a case of hysterical neurosis as a basis for his theories of infantile sexuality. Although tics, abdominal spasms, and sensory disturbances are common observations, the classic picture of conversion hysteria is rarely reported in pediatric literature. The incidence in children is difficult to determine, according to a recent review of the literature by Rock.55 Even the basic texts contain contradictions.6 But as Stevens73$ pointed out, physicians can expect conversion *
Pediatric Psychiatry Liaison. Associate Professor of Psychology, School of Medicine, University of California, Davis, Calif. **
Correspondence to Margaret Steward, Ph.D., Departof Psychiatry, School of Medicine, University of
ment
California
at
Davis, Davis, Calif. 95616.
reactions and conversion symptoms to continue, even though medical advances conquer other diseases. Case Description A 12-year-old white boy (MK) was hospitalized in December, 1972. The previous October he had been rushed by an opposing football player, and his helmeted head had struck the ground. Although he remained lucid, and returned to class, headaches and vomiting began that afternoon. Daily emesis began; over the next eight weeks this was accompanied by vague myalgias, arthralgias, irritability, and insomnia. Emesis was projectile and not preceded by nausea. During these weeks he had a 6.8 kg weight loss and became weak. In a local hospital, his symptoms responded to rest and intravenous fluids. One week after
discharge
he
began
to
complain
of such
pain
and weakness of the lower extremities that he was forced to crawl. Hydrotherapy and hot packs brought transitory relief, but he again lost muscular strength and was reported crawling about his room at home in order to pick up his clothes and keep his room neat. Progressive incoordination with frequent falls and the onset of brief amnesic periods became evident. On January 5, 1973, he was admitted to another hospital for extensive neurologic workup and then transferred to still another hospital with a tentative diagnosis of brain tumor. A psychiatry consultant concluded that this condition had no emotional basis. During the hospitalization, he had a brief episode of generalized tonicity and drooping of the left eyelid. In the week after discharge, he exhibited abdominal twitches and spasms, accompanied by rapid breath-
379
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
These would spontaneously remit to be pain in the lateral rib cage. Weakness persisted and emesis recurred. He showed a positive reaction to the physostigmine test and was given prostigmine, but without persistent relief of symptoms. He was then admitted to the Sacramento Medical Center on December 7, 1973 with differential diagnoses including multiple sclerosis, muscular dystrophy, collagen disease or psychiatric disorder. Past history recorded only the common
ing.
followed by
expect conversion reactions and conversion symptoms
Physicians
can
to
though medical advances conquer other diseases. continue
even
childhood diseases. Family history was pertinent in that the patient was the third of three sons born to a medically oriented family. The father was a Polish immigrant who came to the country following World War II, then worked as a janitor while he attended night school, eventually rising to the position of hospital financial administrator. The mother was a nurse employed at the same hospital and noted for her efficient handling of the emergency room. Both older siblings were asthmatic. The eldest recently had a &dquo;miraculous&dquo; cure immediately prior to the patient’s illness. This brother also sold health foods and vitamins with which the mother had been treating the patient. The family had adopted the mother’s fundamentalist faith, adhering to a strict regimen which forbids television, movies, certain. foods, cigarettes, or alcohol. All sons were described as exceptionally well mannered, pleasant boys. The patient, however, had been a behavior problem in primary school, was severely chastised, and subsequently had become better behaved than even his siblings. On examination, he was thin, tense, fragile appearing and most cooperative. Findings were within the normal range except for symmetric weakness of all extremities. There was a noticeable tremor of the outstretched fingers and he was unable to complete the finger-to-nose test. His gait had a drunken quality so that he stumbled and reeled from wall to wall. Following this demonstration he was able to climb back into bed with ease. A wide diversity of laboratory and x-ray studies, including (in previous hospitalizations) brain scan, spinal x-rays, pneumoencephalogram, myelogram, and cerebral arteriogram, were reported as ’
normal.
During the psychologic evaluation, he talked about his symptoms, his hospitalizations and his own hunches for why he was ill, though with
an obvious attitude of indifference about his illness. He was able to talk about his family’s anxiety in a much more convincing manner than he talked about his own. He was functioning in the bright average level of cognitive development. He showed above average skills on tasks that have perceptual motor components. He showed no evidences of organic deficit
psychosis. Descriptively, ing exceptions or
the test data exhibited some strikto his generally intelligent responses. For example, he refused to answer the question, &dquo;what would you do if a child smaller than you started to fight with you?&dquo; He maintained that no child would do that. When the examiner pursued the question asking if possibly his little sister might raise a hassle, he denied it completely and asked for the pan in which to vomit. Many times he was pulled off the task by personally meaningful components. His drawings of human figures were judged to be developmentally inferior, with a ghostly, asexual quality which suggested a significant denial on the part of the child, probably a denial of his own adolescence. Analysis of the responses to the interpersonal episodes in the &dquo;Tasks of Emotional Development&dquo; indicated that on fully one-third of the cards the adolescent boy pictured was the subject of some severe disease: leukemia, &dquo;multiple skeerosis,&dquo; mononucleosis and vomiting, and rheumatic fever. This compendium of diseases was unusual even for a hospitalized child, and was not woven into the stories in any meaningful way. Thematic material related to the inability to control impulses and the dependency on outside authority to keep him in check, particularly in response to aggressive feelings. There was sufficient evidence from the WISC, Human Figure Drawings, and projective tests to indicate that this boy had considerable difficulty perceiving interpersonal relations and making sense out of them because of the psychologic pain it would cause him. He appeared to be overloaded with rules and regulations from on high, yet feared
Even when an emotional origin is considered early, the kaleidoscope symptoms can easily lead to expensive, unnecessary hospitalizations and risky
diagnostic procedures. he could exercise little control over his aggressive and sexual impulses which were becoming increasingly strong. He appeared to be struggling against making a feminine identification by desexualizing both male and female. The failure
380
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
of repression led to subsequent conversion in a somatic mode of painfully conflicting material. In the hospital he was a model patient, enjoying television and the attention he was receiving. He seemed unconcerned about the future or the possibility of further painful diagnostic procedures. He expressed no anger about late meals or the inevitable inefficiencies. He spoke with warmth about his mother and eldest brother but seemed not to notice that the family did not visit. When he became involved in a game of catch, he could leap about with alacrity. But when a volunteer remarked that he seemed improved, his symptoms immediately worsened. After a discussion and psychologic interpretation of his symptomatic behavior with both parents and MK present, MK’s gait improved to the extent that he could walk unaided from the hospital. A follow-up interview one month after discharge revealed that the mother had decided against psychiatric treatment although the father still felt treatment to be advisable. Although MK
was
no
longer weak,
he
was
producing
eructations loud enough to disturb his classroom. This symptom’ was not nearly so dramatic, but it was sufficient to keep him home with his mother.
Discussion As illustrated by this case, the recognition of conversion hysteria can be difficult. Even when an emotional origin is considered early, the kaleidoscope symptoms can easily lead to expensive, unnecessary hospitalizations and risky diagnostic procedures. In the interim, the pattern of illness may take on added value to the patient. Our youngster had indications of hysteria which if considered together might have led to an earlier diagnosis. Especially noticeable was the generalized inhibition of expression of anger which did not allow MK to be bothered by hospital delays nor by the rigid restrictions of his family. The development of adolescent sexuality was similarly prohibited with MK’s attitudes and interests appearing as that of a much younger child. These inhibitions were encouraged and suggested by the family as demonstrating good character. He also had an unusual degree of compliance to even painful procedures. His role as a smiling model patient elicited first warmth and respect from the
hospital personnel but later was seen as inappropriate and therefore distrusted. His lack of concern for bodily injury or. eventual outcome was interpreted by some as immaturity and others as denial of painful reality rather than &dquo;la belle indifference.&dquo; In addition to these observations, a careful review of the history showed many
discrepancies-the insignificance of the original injury, the effervescence of symptoms, etc.
After
diagnosis had been substantiated by psychologic testing and observation, we perceived the problem and interpreted it to the patient and his family. What we failed to do was to fully assess the value of the illness to the family. The mother’s resistance to the treatment of her son was not anticipated and the pattern of illness changed, with eructations replacing paralysis. As Rock’ indicated, mothers of hysterical children tend to be overprotective and fathers distant or ineffectual. In addition, parents may subtly encourage the development of symptoms through the alerting and focusing of their own anxieties. Even with insight into the child’s problems, change may be resisted. Our
our
case
It is
supports these observations.
hypothesis that intervention in hysteria may be difficult, because though debilitating physically, the condition is important within the emotional dynamics of the family. As a consequence, treatment recommendations may be ignored in order our
conversion
to
preserve that emotional balance.
Final Comment
When confronted with discrepancies in combined with an overly compliant child who exhibits seeming lack of concern, the practicing pediatrician should consider the possibility of conversion hysteria. A strict and often religious family whose members inhibit expression of strong negative feelings is another important clue to this
history
diagnosis. To be effective, intervention must include attention to the family dynamics which may be protecting or even encouraging the expressions of illness. 381
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
References 1.
K.: Hysteria. In Keating, J. M., Ed. Cyclopedia of the Diseases of Children—Medical and Surgical. Philadelphia, J. B. Lippincott
—:
5.
Rock, N. L.: Conversion reactions
Vol. 1, 1959.
Mills, C.
Co., Vol. 4, 958-1890, 1890. 2. Freud, S.: Early studies on the psychical mechanism of hysterical phenomena. In J. Strachey, Ed. Collected Papers. New York, Basic Books, Vol. 5, 1959.
Management of an analysis of a case of hysteria. In J. Strachey, Ed. Collected Papers.
3. —: New
York, Basic Books, Vol. 3, 1959.
The aeteology of hysteria. In J. Strachey, Ed. Collected Papers. New York, Basic Books,
4.
in childhood: clinical study on childhood neuroses. J. Am. Acad. Child Psychiatr. 10: 65, 1971. 6. Nelson, W. E.: Textbook of Pediatrics, 8th ed. W. B. Saunders, 1964. 7. Stevens, H.: Conversion hysteria: a neurologic emergency. Mayo Clin. Proc. 43: 54, 1968. 8. Stevens, H.: Conversion hysteria revisited by the pediatric neurologist. Clin. Proc. Child. Hosp. (DC) 25: 27, 1969. a
Philadelphia,
Many different kinds of microorganisms cause enteric disease, but Environn9enta~ Sanitation transmission generally depends on Can Control Enteric
fecal contamination. All these infections generally have
Infections
a common source:
namely, human in the wrong place-in water, in food, on the hands, and frequently on household facilities and equipment. In Central and South America, enteric infections constitute one of the leading causes of disease and death. To change this picture, we need many more water and sewerage systems, better food preparaexcreta
tion and
handling, and public comprehension of how elementary good hygiene promotes good health. Attaining these objectives will be less costly than one might suppose, and there is little to be gained by delay. The basic environmental causes of enteric disease are clear, current conditions have been aggravated by rapid population growth and urbanization, and basic corrective measures have been postponed long enough.-Abel Wohman in Bulletin of the Pan American Health Organization, 1975.
382
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
’
Conversion
Hysteria A Case
in Childhood
Report and
a
Reminder
Alayne Yates, M.D.,* Margaret Steward,
Ph.D.**
’ ’
i i1 1YSTERIA&dquo; //
is
derived
by Hippocrates &dquo;Hysteron,&dquo; meaning uterus. Hippocrates thought that the condition resulted from the migration of the uterus in widows and spinsters. An exclusively physical cause continued to be presumed until Mills wrote in 1890 that &dquo;hysteria in children a
term
from the Greek
has therefore no morbid anatomy that can be discriminated either by scalpel or microscope... and the psychical element must enter into the explanation of nearly all cases.&dquo;’ Interest in this condition reached new heights in the late 19th century with
dramatic cures by the use of hypnosis. Freud 2-4 employed his painstaking analysis of a case of hysterical neurosis as a basis for his theories of infantile sexuality. Although tics, abdominal spasms, and sensory disturbances are common observations, the classic picture of conversion hysteria is rarely reported in pediatric literature. The incidence in children is difficult to determine, according to a recent review of the literature by Rock.55 Even the basic texts contain contradictions.6 But as Stevens73$ pointed out, physicians can expect conversion *
Pediatric Psychiatry Liaison. Associate Professor of Psychology, School of Medicine, University of California, Davis, Calif. **
Correspondence to Margaret Steward, Ph.D., Departof Psychiatry, School of Medicine, University of
ment
California
at
Davis, Davis, Calif. 95616.
reactions and conversion symptoms to continue, even though medical advances conquer other diseases. Case Description A 12-year-old white boy (MK) was hospitalized in December, 1972. The previous October he had been rushed by an opposing football player, and his helmeted head had struck the ground. Although he remained lucid, and returned to class, headaches and vomiting began that afternoon. Daily emesis began; over the next eight weeks this was accompanied by vague myalgias, arthralgias, irritability, and insomnia. Emesis was projectile and not preceded by nausea. During these weeks he had a 6.8 kg weight loss and became weak. In a local hospital, his symptoms responded to rest and intravenous fluids. One week after
discharge
he
began
to
complain
of such
pain
and weakness of the lower extremities that he was forced to crawl. Hydrotherapy and hot packs brought transitory relief, but he again lost muscular strength and was reported crawling about his room at home in order to pick up his clothes and keep his room neat. Progressive incoordination with frequent falls and the onset of brief amnesic periods became evident. On January 5, 1973, he was admitted to another hospital for extensive neurologic workup and then transferred to still another hospital with a tentative diagnosis of brain tumor. A psychiatry consultant concluded that this condition had no emotional basis. During the hospitalization, he had a brief episode of generalized tonicity and drooping of the left eyelid. In the week after discharge, he exhibited abdominal twitches and spasms, accompanied by rapid breath-
379
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
These would spontaneously remit to be pain in the lateral rib cage. Weakness persisted and emesis recurred. He showed a positive reaction to the physostigmine test and was given prostigmine, but without persistent relief of symptoms. He was then admitted to the Sacramento Medical Center on December 7, 1973 with differential diagnoses including multiple sclerosis, muscular dystrophy, collagen disease or psychiatric disorder. Past history recorded only the common
ing.
followed by
expect conversion reactions and conversion symptoms
Physicians
can
to
though medical advances conquer other diseases. continue
even
childhood diseases. Family history was pertinent in that the patient was the third of three sons born to a medically oriented family. The father was a Polish immigrant who came to the country following World War II, then worked as a janitor while he attended night school, eventually rising to the position of hospital financial administrator. The mother was a nurse employed at the same hospital and noted for her efficient handling of the emergency room. Both older siblings were asthmatic. The eldest recently had a &dquo;miraculous&dquo; cure immediately prior to the patient’s illness. This brother also sold health foods and vitamins with which the mother had been treating the patient. The family had adopted the mother’s fundamentalist faith, adhering to a strict regimen which forbids television, movies, certain. foods, cigarettes, or alcohol. All sons were described as exceptionally well mannered, pleasant boys. The patient, however, had been a behavior problem in primary school, was severely chastised, and subsequently had become better behaved than even his siblings. On examination, he was thin, tense, fragile appearing and most cooperative. Findings were within the normal range except for symmetric weakness of all extremities. There was a noticeable tremor of the outstretched fingers and he was unable to complete the finger-to-nose test. His gait had a drunken quality so that he stumbled and reeled from wall to wall. Following this demonstration he was able to climb back into bed with ease. A wide diversity of laboratory and x-ray studies, including (in previous hospitalizations) brain scan, spinal x-rays, pneumoencephalogram, myelogram, and cerebral arteriogram, were reported as ’
normal.
During the psychologic evaluation, he talked about his symptoms, his hospitalizations and his own hunches for why he was ill, though with
an obvious attitude of indifference about his illness. He was able to talk about his family’s anxiety in a much more convincing manner than he talked about his own. He was functioning in the bright average level of cognitive development. He showed above average skills on tasks that have perceptual motor components. He showed no evidences of organic deficit
psychosis. Descriptively, ing exceptions or
the test data exhibited some strikto his generally intelligent responses. For example, he refused to answer the question, &dquo;what would you do if a child smaller than you started to fight with you?&dquo; He maintained that no child would do that. When the examiner pursued the question asking if possibly his little sister might raise a hassle, he denied it completely and asked for the pan in which to vomit. Many times he was pulled off the task by personally meaningful components. His drawings of human figures were judged to be developmentally inferior, with a ghostly, asexual quality which suggested a significant denial on the part of the child, probably a denial of his own adolescence. Analysis of the responses to the interpersonal episodes in the &dquo;Tasks of Emotional Development&dquo; indicated that on fully one-third of the cards the adolescent boy pictured was the subject of some severe disease: leukemia, &dquo;multiple skeerosis,&dquo; mononucleosis and vomiting, and rheumatic fever. This compendium of diseases was unusual even for a hospitalized child, and was not woven into the stories in any meaningful way. Thematic material related to the inability to control impulses and the dependency on outside authority to keep him in check, particularly in response to aggressive feelings. There was sufficient evidence from the WISC, Human Figure Drawings, and projective tests to indicate that this boy had considerable difficulty perceiving interpersonal relations and making sense out of them because of the psychologic pain it would cause him. He appeared to be overloaded with rules and regulations from on high, yet feared
Even when an emotional origin is considered early, the kaleidoscope symptoms can easily lead to expensive, unnecessary hospitalizations and risky
diagnostic procedures. he could exercise little control over his aggressive and sexual impulses which were becoming increasingly strong. He appeared to be struggling against making a feminine identification by desexualizing both male and female. The failure
380
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
of repression led to subsequent conversion in a somatic mode of painfully conflicting material. In the hospital he was a model patient, enjoying television and the attention he was receiving. He seemed unconcerned about the future or the possibility of further painful diagnostic procedures. He expressed no anger about late meals or the inevitable inefficiencies. He spoke with warmth about his mother and eldest brother but seemed not to notice that the family did not visit. When he became involved in a game of catch, he could leap about with alacrity. But when a volunteer remarked that he seemed improved, his symptoms immediately worsened. After a discussion and psychologic interpretation of his symptomatic behavior with both parents and MK present, MK’s gait improved to the extent that he could walk unaided from the hospital. A follow-up interview one month after discharge revealed that the mother had decided against psychiatric treatment although the father still felt treatment to be advisable. Although MK
was
no
longer weak,
he
was
producing
eructations loud enough to disturb his classroom. This symptom’ was not nearly so dramatic, but it was sufficient to keep him home with his mother.
Discussion As illustrated by this case, the recognition of conversion hysteria can be difficult. Even when an emotional origin is considered early, the kaleidoscope symptoms can easily lead to expensive, unnecessary hospitalizations and risky diagnostic procedures. In the interim, the pattern of illness may take on added value to the patient. Our youngster had indications of hysteria which if considered together might have led to an earlier diagnosis. Especially noticeable was the generalized inhibition of expression of anger which did not allow MK to be bothered by hospital delays nor by the rigid restrictions of his family. The development of adolescent sexuality was similarly prohibited with MK’s attitudes and interests appearing as that of a much younger child. These inhibitions were encouraged and suggested by the family as demonstrating good character. He also had an unusual degree of compliance to even painful procedures. His role as a smiling model patient elicited first warmth and respect from the
hospital personnel but later was seen as inappropriate and therefore distrusted. His lack of concern for bodily injury or. eventual outcome was interpreted by some as immaturity and others as denial of painful reality rather than &dquo;la belle indifference.&dquo; In addition to these observations, a careful review of the history showed many
discrepancies-the insignificance of the original injury, the effervescence of symptoms, etc.
After
diagnosis had been substantiated by psychologic testing and observation, we perceived the problem and interpreted it to the patient and his family. What we failed to do was to fully assess the value of the illness to the family. The mother’s resistance to the treatment of her son was not anticipated and the pattern of illness changed, with eructations replacing paralysis. As Rock’ indicated, mothers of hysterical children tend to be overprotective and fathers distant or ineffectual. In addition, parents may subtly encourage the development of symptoms through the alerting and focusing of their own anxieties. Even with insight into the child’s problems, change may be resisted. Our
our
case
It is
supports these observations.
hypothesis that intervention in hysteria may be difficult, because though debilitating physically, the condition is important within the emotional dynamics of the family. As a consequence, treatment recommendations may be ignored in order our
conversion
to
preserve that emotional balance.
Final Comment
When confronted with discrepancies in combined with an overly compliant child who exhibits seeming lack of concern, the practicing pediatrician should consider the possibility of conversion hysteria. A strict and often religious family whose members inhibit expression of strong negative feelings is another important clue to this
history
diagnosis. To be effective, intervention must include attention to the family dynamics which may be protecting or even encouraging the expressions of illness. 381
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
References 1.
K.: Hysteria. In Keating, J. M., Ed. Cyclopedia of the Diseases of Children—Medical and Surgical. Philadelphia, J. B. Lippincott
—:
5.
Rock, N. L.: Conversion reactions
Vol. 1, 1959.
Mills, C.
Co., Vol. 4, 958-1890, 1890. 2. Freud, S.: Early studies on the psychical mechanism of hysterical phenomena. In J. Strachey, Ed. Collected Papers. New York, Basic Books, Vol. 5, 1959.
Management of an analysis of a case of hysteria. In J. Strachey, Ed. Collected Papers.
3. —: New
York, Basic Books, Vol. 3, 1959.
The aeteology of hysteria. In J. Strachey, Ed. Collected Papers. New York, Basic Books,
4.
in childhood: clinical study on childhood neuroses. J. Am. Acad. Child Psychiatr. 10: 65, 1971. 6. Nelson, W. E.: Textbook of Pediatrics, 8th ed. W. B. Saunders, 1964. 7. Stevens, H.: Conversion hysteria: a neurologic emergency. Mayo Clin. Proc. 43: 54, 1968. 8. Stevens, H.: Conversion hysteria revisited by the pediatric neurologist. Clin. Proc. Child. Hosp. (DC) 25: 27, 1969. a
Philadelphia,
Many different kinds of microorganisms cause enteric disease, but Environn9enta~ Sanitation transmission generally depends on Can Control Enteric
fecal contamination. All these infections generally have
Infections
a common source:
namely, human in the wrong place-in water, in food, on the hands, and frequently on household facilities and equipment. In Central and South America, enteric infections constitute one of the leading causes of disease and death. To change this picture, we need many more water and sewerage systems, better food preparaexcreta
tion and
handling, and public comprehension of how elementary good hygiene promotes good health. Attaining these objectives will be less costly than one might suppose, and there is little to be gained by delay. The basic environmental causes of enteric disease are clear, current conditions have been aggravated by rapid population growth and urbanization, and basic corrective measures have been postponed long enough.-Abel Wohman in Bulletin of the Pan American Health Organization, 1975.
382
Downloaded from cpj.sagepub.com at UQ Library on June 13, 2015
’
