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Clinical Case Conference   |    
Treatment of Conversion Disorder in an African American Christian Woman: Cultural and Social Considerations
Ann C. Schwartz, M.D.; Amanda W. Calhoun, M.D., M.P.H.; Cheryl L. Eschbach, M.D., Ph.D.; Beth J. Seelig, M.D.
Am J Psychiatry 2001;158:1385-1391. doi:10.1176/appi.ajp.158.9.1385

Conversion disorder, one of the somatoform disorders, is characterized by 1) unexplained symptoms affecting voluntary motor or sensory function in ways that suggest neurological disease and 2) the presence of conflicts that play a significant role in initiating, exacerbating, and maintaining the disturbance (DSM-IV). Dating back to ancient times, conversion symptoms have been ascribed to many different mechanisms. The most influential theory perhaps was "wandering of the uterus," from which were derived the term "hysteria" and the erroneous assumption that conversion symptoms are peculiar to females (1). The term "conversion" was first used by Freud and Breuer in reference to the substitution of a somatic symptom for a repressed idea (2). Freud then worked out his concept of talking therapy as a catharsis through which unconsciously repressed material might become conscious. In addition to the psychodynamic formulations, other etiologies have more recently been proposed; these include social and communication theories, behavioral theories, and proposed neurophysiologic deficits (3).

As conversion disorder is relatively common, with some studies suggesting a lifetime prevalence of up to 33% (4), it is worthwhile isolating population-specific themes that may be helpful to both the treating psychiatrist and the referring physician. The patient in our clinical case, Ms. K (a pseudonym), was an African American woman who was seen by the adult psychiatry consultation-liaison service of a major teaching hospital. Ms. K was initially admitted to the neurological service suffering from dysarthric speech and other associated seemingly neurological symptoms. These symptoms proved to be the somatic expression of severe conflicting internal and external demands, many of which appeared to be rooted in her religious beliefs. In this clinical case conference, we will demonstrate the role of sociocultural influences in the development of Ms. K’s symptoms, describing some of the complex specific sociocultural issues that contribute to the pathogenesis of conversion disorder in devoutly religious African American Christian women. Sensitivity to the complex issues of religion, race, and gender is essential in formulating an effective biopsychosocial treatment plan for such a woman. The interdisciplinary approach presented here can be valuable to the physician, who may differ in religious background, race, and gender from the patient.

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Initial Presentation and History of Current Illness

Ms. K was a 37-year-old African American woman who was seen in the emergency room in June 1999 with a 1-month history of severe occipital headaches and a 2-day history of dysarthria, difficulty in hearing, and gait difficulties. She was discharged from the emergency room after receiving a computerized tomography (CT) scan of her head, the result of which was negative, and consultation from the neurology service, which found no objective basis for her symptoms. Ms. K returned to the emergency room 2 weeks later, complaining of no improvement in her symptoms and the onset of additional symptoms, including diplopia and vertigo. During a physical examination, a palsy involving the sixth nerve and dysarthric speech were observed, and Ms. K was admitted to the inpatient neurology service.

The noncontrast CT head scan done during the initial emergency room visit showed no evidence of acute intracranial hemorrhage, fractures, or abnormal densities. The results of serum blood tests for HIV and syphilis were negative. The result of a magnetic resonance imaging scan of the brain with gadolinium magnetic resonance angiography also was negative, with no evidence of demyelinating plaques or other disease processes unlikely to be seen on CT. While on the inpatient neurology service unit, Ms. K was found to have a "factitious lateral gaze palsy," whereby when gazing to the right, she used convergence to adduct her right eye while her left eye moved toward the right. The results of the neurological examination were otherwise unremarkable with the exception of an "astasia-abasia" gait, characterized by underlying "good coordination with the ability to catch herself." A normal saline placebo was administered, along with the suggestion that the electrolyte solution would ameliorate her symptoms. Slight improvement was subsequently noted in her speech, gait, and eye movements, but the dysarthria did not remit at all.

Shortly after being informed that her symptoms most likely did not have a neurologic basis, Ms. K complained of feeling severely depressed. A house staff officer also stated that she had reported auditory hallucinations commanding her to kill herself. Suicide precautions were taken, Ms. K was placed under one-to-one direct observation, and the psychiatry service was consulted.

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Additional History

Ms. K was born and raised in Miami, the third of eight children. Her parents divorced in 1969, when Ms. K was 7 years old. Her father "abducted" her at that time, and she lived with him until age 11, when her mother finally "recovered" her. She reported severe physical and emotional abuse during the 4 years that she lived with her father. She was beaten on average two times a week. She said that she was sometimes locked in a cage for hours at a time with her father’s dogs. According to Ms. K, she was singled out from her siblings by her father because she was the oldest daughter and she most resembled her mother, toward whom her father had substantial feelings of animosity. Despite giving this history, Ms. K insisted that she now loved her father and bore no ill will toward him.

Ms. K reported enjoying school and doing well academically. She participated in extracurricular activities, including the debate team. Her mother was well educated and expected Ms. K and her siblings to achieve. But Ms. K’s ability to continue in her scholastic success was undermined when, at the age of 16, she was raped by an acquaintance. She stated that this traumatic event disrupted her studies, and she was unable to complete high school. Shortly after her withdrawal from high school, she began investing her energy and talents in religious pursuits. Raised a Baptist, she now became a member of the Holiness Church, which was a precursor to the Pentecostal religious movement that emphasizes God’s intervention in human affairs through the Holy Spirit.

At the age of 19, in a match arranged by the church, she married her then 26-year-old husband. They received missionary training through the church and were sent to serve as ministers of a congregation in Atlanta. They had three children, who were 15, 17, and 18 years old when Ms. K was seen in the psychiatry service. She took over the ministry of the church on a full-time basis after her husband was incarcerated on charges of embezzlement. She said that she remained close to her husband in spite of his incarceration and also despite other unwelcome news, including the revelation that he had a long history of homosexual relationships. He died while in prison in 1996 from an AIDS-related illness.

Eventually, Ms. K founded another ministry, an inner-city religious outreach program funded in part by a Lutheran church. For the previous decade, the outreach program had thrived, and through it she operated both a spiritual ministry and a food kitchen. She boasted that she was feeding "300–400 homeless persons per day in [her] spare time." She lived with her children and had many close friends and associates.

Initially, Ms. K denied any psychiatric history. Nevertheless, she soon admitted that she had experienced depressive symptoms at approximately age 22 but did not seek treatment at that time. She also reported feeling depressed when her husband was arrested and incarcerated for embezzlement. She reported having suicidal ideation at the time but adamantly denied having attempted any self-harm, stating that, "[suicide] is a sin before God."

Ms. K reported multiple recent stressors and losses. She described having been beaten by men who broke into her house to rob her, saying she thought they had followed her home from the mission. She felt "helpless" at that time. In addition, she was very distressed about the recent rape of one of her daughters. Furthermore, she was also attempting to cope with the news of the out-of-wedlock pregnancy of her other daughter, as well as this daughter’s consideration of the possibility of aborting the fetus. She expressed her guilt about not being close enough to her children when they were younger. She spontaneously interpreted her current symptoms as the result, in part, of a "spiritual attack," explaining that in her church it is taught that the Devil does such things to people and that faith and prayer are the only remedy.

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Mental Status Examination

Ms. K appeared as a sturdily built African American woman, with fair grooming and hygiene, sitting up in the hospital bed. She was friendly and cooperative with the interview, although somewhat guarded. Good eye contact was preserved throughout the interview. She spoke slowly and with apparent difficulty and had an exaggerated Cajun-sounding accent. She made almost tortured-appearing movements of her mouth, with her tongue occasionally clicking loudly against the roof of her mouth. This speech pattern waxed and waned without a discernible pattern, and at times her speech became normal, with appropriate tone and good enunciation. As she spoke, Ms. K gestured in strange, dramatic motions, with her hands flexed backward and fingers stiffly spread in a claw-like posture. Ms. K described her mood as "sad," and her affect was dysphoric. Her thought processes were slow, but not impoverished, and overall were logical and goal directed. Her thought content was significant for mild grandiosity at times, including occasional mention of personal friendships with well-known persons in Atlanta. When asked about her earlier statements about demons and hurting herself, she explained that the neurology service’s conclusion was a misunderstanding. She clarified that she is a very religious person, and she felt as though she was under "spiritual attack." She reported having no suicidal ideation during the interview, stating categorically her belief that it is a sin to kill oneself. She reported having no homicidal ideation. Ms. K appeared to have fair insight into the fact that she was under tremendous stress and that this might have contributed to her symptoms. Her judgment and impulse control were deemed good. She scored 26 out of 30 on the Mini-Mental State Examination; she lost points on orientation (2 points), recall (1 point), and repetition (1 point).

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Differential Diagnosis

At the outset, the differential diagnosis of Ms. K included neurological conditions, such as multiple sclerosis, optic neuritis, brain tumor, subdural hematoma, early manifestations of AIDS, and neurosyphilis. Multiple sclerosis and optic neuritis could have caused a lateral gaze palsy. A tumor in the area of her vocal cords would result in dysarthria. A subdural hematoma might have accounted for the excruciating headache. AIDS could easily have led to multiple CNS lesions with diverse neurological findings. Neurosyphilis could have contributed to ataxia.

These conditions having been ruled out by Ms. K’s extensive medical and neurological work-up, the differential diagnosis now included psychiatric conditions, such as factitious disorder with predominantly physical signs and symptoms, malingering, somatization disorder, histrionic personality disorder, and posttraumatic stress disorder (PTSD), in addition to conversion disorder. In factitious disorder, in which patients consciously feign symptoms for unconscious reasons, patients often have a coexisting histrionic, borderline, or antisocial personality disorder and typically travel from hospital to hospital in search of care. In malingering, in which patients consciously feign symptoms for consciously understood reasons, it is not uncommon for patients to have pending legal charges or serious financial problems that a new medical diagnosis would conveniently postpone. Patients with somatization disorder typically have multiple symptoms, including pain at multiple sites, gastrointestinal symptoms, and a sexual or reproductive symptom in addition to a neurological symptom. In histrionic personality disorder, prominent symptoms include excessive emotionality and attention seeking, with self-dramatization, theatricality, and exaggerated expressions. In PTSD, a traumatic event must be persistently reexperienced in the form of distressing thoughts, perceptions, dreams, or reliving accompanied by intense psychological or physiological reactivity due to reminders of the event.

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Treatment

The attending consultation-liaison psychiatrist evaluating Ms. K (B.J.S.) concluded that the belief in a "spiritual attack" was culturally syntonic and not delusional. Ms. K was given the diagnosis of conversion disorder on the basis of a lack of organic basis for the symptoms coupled with observations of her response to trial interpretations made during the 60-minute bedside psychiatric interview. During this interview, it was learned that Ms. K’s younger sister, an important female family member, had suffered an aneurysm in her leg with resultant paralysis. In addition, Ms. K’s aunt died at the age of 30 from a brain aneurysm, and two grandparents died as the result of strokes. When Ms. K was asked directly if she was angry, she said, "No," going on to explain that in her faith anger is not acceptable. However, when the psychiatrist said, "Many people in your situation would be furious," she readily agreed and seemed pleased. Following this clarification, the psychiatrist interpreted, "I think that it is tremendously difficult to be stuck in this situation in which any person would have reason to be angry, even at God, and your faith forbids you to feel angry." Speaking more fluently, Ms. K reiterated that she was not angry, but she went on to give more details about the terrible events in her life. It was apparent that despite her denial, she was indeed struggling not to feel anger. The psychiatrist then told Ms. K that the inability to speak clearly was connected to both wanting and not wanting to cry out against what had happened. Ms. K became thoughtful, and although she did not agree verbally, her speech continued to improve and her hands relaxed somewhat. She was told that it is important to realize that no human being is perfect and that feeling that she should never be angry becomes a tremendous burden when the people you love let you down. Ms. K then said that as the preacher, she has to practice what she preaches and that she is a role model. The psychiatrist said that sometimes being a role model is very difficult, and Ms. K agreed. These interpretations were carefully tailored not to directly confront Ms. K’s denial.

Given her multiple life stressors and the persisting dysarthric speech and other associated symptoms described earlier, coupled with the improvement in symptoms during the course of the interview, an initial period of inpatient psychiatric hospitalization was recommended. It was hoped that further evaluation and psychotherapy could begin in a safe supportive environment, as the degree of functional impairment was great and might be lasting if not treated intensively from the outset. Ms. K refused. She was discharged from the neurology service and referred for individual supportive psychotherapy with the goal of helping with stress management and addressing some of the underlying issues troubling her. She was seen in weekly individual supportive psychotherapy by a psychiatric resident for approximately 12 weeks. During this period, although Ms. K’s symptoms waxed and waned somewhat in intensity, her condition remained essentially unchanged. Finally, at the urging of her outpatient psychiatrist, she agreed to voluntary hospitalization.

During this hospitalization, gentle efforts were made to explore the relationship between possible social and psychological stressors and the onset of her symptoms. Ms. K seemed to give particular emphasis to events occurring in mid-June 1999, when she was giving a sermon in a church in her hometown of Miami. While talking, she had the sense that she was suddenly hit in the back of the head. She said that she became speechless and then fell to the floor. Her next conscious memory, she recounted, was of being "revived" 2 days later to find herself in a Miami hospital (from which she was discharged with instructions to follow up at the large teaching hospital in Atlanta). While she initially reported that the dysarthria and ataxia followed the headache by at least several days, she now suggested that all symptoms had an acute onset at the time of the sermon. She called this event her "French stroke," referring perhaps humorously to the peculiar, Cajun-sounding accent with which she spoke in its wake. Ms. K seemed eager to discuss the specific setting in which the "French stroke" occurred and the consequent physical impairments she experienced, but she was quite guarded about possible psychosocial stressors and did not voluntarily identify any specific events that she felt might have been important in symptom formation.

Nevertheless, in talking with Ms. K, several important stressors stood out. First, the episode in mid-June occurred in the context of her first visit in a dozen years to Miami, where she grew up. Second, during this visit she stayed with her mother and began to talk with her mother for the first time in many years about sensitive subjects, including the fact that as a child she had been left to live with her abusive father after her parents’ divorce. Third, Ms. K reported unsuccessfully attempting to visit her father, now a wealthy businessman, and being thrown off the premises of his home by a security guard. She denied knowing whether this attempt to reestablish ties with her father occurred before or after the "stroke" of mid-June, again possibly showing her inability or unwillingness to relate specific stressful events to the conversion symptoms.

On hospital day 5, Ms. K allowed herself to be interviewed and then hypnotized by a psychiatrist with the consultation-liaison service, with the behavioral objective of using suggestion to produce symptom relief. The intention of hypnosis was neither to confront Ms. K with freshly retrieved unconscious material believed to be the cause of her disorder nor to attempt a dramatic cure, but to help Ms. K recall experiences and feelings that she could not consciously bring up in treatment (5). During the interview, she offered more details about the physical experiences associated with her conversion symptoms, but again she was unable or unwilling to provide insight into psychosocial stressors that may have contributed to the formation of her symptom complex. Of note, however, during the hypnosis, her hands relaxed, reverting to almost normal. Her speech became much more fluent and spontaneous. Afterward, her gait was noticeably improved and she walked without a cane. Her dysarthria and awkward hand posturing remained in nearly full remission.

Hypnosis in the hospital proved to be a very productive exercise with Ms. K. She was highly suggestible and was intrigued by her ability to reverse her deficits given the encouragement of the attending psychiatrist. She expressed a desire to learn such techniques, highlighting a conscious desire to be "cured." While Ms. K was delighted and amazed by her response to hypnosis, she also admitted to feeling anxiety and a "racing heart" during the procedure. She was given a long-acting benzodiazepine, clonazepam, 1 mg b.i.d., to alleviate the anxiety and maintain symptom remission, with the plan gradually to taper the medication when Ms. K became an outpatient. Ms. K took the anxiolytic medication for several days, but she did not like the sedating effects, so it was discontinued.

Ms. K was now receptive to the idea that, given the possibility that her deficits were reversible, there might be some precipitating factors that were blocking her ability to function in her usual fashion. Thus, her inpatient treatment team planned for Ms. K to eventually resume outpatient supportive psychotherapy with her previous psychotherapist in order to address these issues. On hospital day 10, Ms. K was discharged from the inpatient unit to a 3-week partial hospitalization program that was to serve as a bridge between intensive inpatient treatment and her return to everyday life with once-weekly outpatient psychotherapy. At the time of discharge, she continued to believe that she had suffered a stroke. The treatment team did not directly contradict this belief, as such confrontation is generally not helpful for patients with conversion disorder and can generate an adversarial relationship. Although factitious disorder and malingering were considered in the differential diagnosis, the treatment team felt that Ms. K’s symptoms were not under conscious or voluntary control.

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Brief Review of Conversion Disorder

Conversion disorders are the most frequently occurring of the seven clinical syndromes gathered together under somatoform disorders. Three key features characterize a conversion reaction. First is the sudden or insidious onset of symptoms or deficits affecting voluntary motor or sensory function in ways that suggest neurological disease but in fact do not conform to the anatomy or physiology of the central or peripheral nervous system. Second is the absence of conscious, volitional activity; these symptoms or deficits are not willed or feigned. Third is the presence of severe internal and external conflicts that appear to play an important part in creating, exacerbating, and maintaining the condition (5). Examples of conversion disorder symptoms are unexplained blindness, diplopia, seizures, anesthesia, aphonia, amnesia, and difficulty walking (6).

The annual incidence of conversion disorders seen by psychiatrists is approximately 22 cases per 100,000 (7). In a general hospital setting, 5%–14% of all psychiatric consultation patients are referred for assistance in the diagnosis and management of conversion symptoms (79). Engel (9) estimated that 20% to 25% of patients admitted to general medical services have had conversion symptoms at some time in their lives. Conversion symptoms are seen in both men and women but are most common in young women (6, 10). The symptoms have been noted at every age, although they are rare in children younger than 7 or 8 and probably do not occur in children under 4 (11). Traditionally, the prevalence of the disorder has been the highest in rural areas and among the undereducated and the lower socioeconomic classes (7).

The most well-known explanation of conversion disorder draws from psychoanalytic theory, in particular its emphasis on unconscious drives and the defense mechanisms used against the potentially destructive effects of those drives. Indeed, Freud was led to his discovery of the unconscious mind through his analysis of Anna O. and other patients with conversion symptoms. Through the use of hypnosis and later the psychoanalytic technique of free association, Freud was able to uncover the intrapsychic conflicts that, in his view, are the cause of conversion symptoms. These conflicts are usually over drives and needs such as sexuality, aggression, or dependency and internalized prohibitions against their expression (5, 6, 12). The physical symptom manifested in the conversion reaction allows a partial expression of a forbidden wish or urge but also disguises it. This somatic disguise serves to keep unacceptable impulses out of conscious awareness while also expressing them in symbolic form, thus providing a solution to an unconscious conflict (3, 5). Conversion symptoms may also be interpreted psychodynamically as a need to suffer or as identification with a lost object (3, 9). In the case of Ms. K, her "French stroke" could be viewed as representing identification with her sister, aunt, or grandparents.

An alternative approach to the psychodynamic literature is learning theory, which derives from the behavioral tradition in psychiatry. The central assumption of this literature is that human behavior is shaped by what is absorbed and ultimately "learned" from the environment. With respect to conversion disorder and other hysterical conditions, behaviorists typically regard the symptoms as operant behaviors; that is, the patient’s symptomatic behavior acts on the environment to produce reinforcing consequences or secondary gains that maintain or strengthen the symptoms (13). McHugh and Slavney (14) postulated that patients are motivated "more or less unwittingly" to believe that they have a particular neurological affliction in order to achieve the "sick-role" with its attendant privileged social status. Patients then learn the behavior that reflects their belief that they are ill and their particular idea of their supposed affliction. In turn, conversion disorder is sustained by the effects of these behaviors on people who observe them. A sort of vicious circle evolves in which the patient’s beliefs are acquired from multiple external cues, and these beliefs in turn are amplified and sustained by the attention and rewards that the patient receives from observers: "Beliefs of the patient and beliefs in the community reinforce and sustain each other" (14).

The therapeutic implications of learning theory are very different from those of the psychodynamic school. While the psychodynamic approach emphasizes resolution of the unconscious conflict, learning theory seeks to alter the patient’s belief by the means of countersuggestion and psychosocial measures that effectively decrease the external benefits associated with assumption of the sick role. For the behavior therapist, conversion disorder represents behavioral excesses and deficits in the patient’s repertoire. Therefore, in order for the patient to function in a socially adaptive fashion, these behaviors must be modified. The common objective of all behavioral approaches is to alter the relationship between behaviors and their consequences in such a way that it becomes of greater benefit to the patient to relinquish the symptoms than to maintain them (13).

Yet a third approach to conversion disorder focuses on the importance of sociocultural considerations in the evolution of the symptoms. In contrast to learning theory and the behavioral tradition more generally, which posits itself as an alternative to the psychoanalytic tradition, the sociocultural approach is complementary to both psychoanalytic and behavioral understandings, emphasizing the interaction between the external environment and the complex, often unconscious, intrapsychic conflicts of the patient. It accepts as fundamental the psychodynamic idea that conversion symptoms express forbidden ideas. Hollender suggested that some of the culture-bound syndromes, such as "running amok," are a means of expressing anger and rage when it is not culturally permissible to do so verbally (3, 15). In addition, it has been hypothesized that the belief in some cultures that the direct expression of intense emotions is "not acting like a lady" may predispose women to conversion symptoms as a more acceptable means of communication (3, 16). The conversion symptoms communicate somatically the emotionally charged feelings or ideas that have been blocked from conscious understanding and expression. We hypothesize that what blocks their expression, in many cases, are internalized prohibitions that are powerfully reinforced by gender roles, religious beliefs, and other social and cultural influences. By recognizing these influences, we can better understand the strange physical pantomime of threatening ideas or feelings that conversion symptoms effectively enact (3).

In recent years, there has been increasing interest in the possibility that conversion symptoms have a neurophysiologic component. The work of Flor-Henry et al. on the etiopathology of conversion disorder demonstrates impairment of both the dominant and nondominant hemispheres, with the impairment being greater for the dominant hemisphere (3, 17). Neuropsychological tests of patients with conversion disorder demonstrate impaired vigilance-attention and short-term memory, excessive field dependency, and heightened suggestibility (18). Taken together, these findings suggest that patients with conversion disorder can experience impaired intercortical communication and blockade of ordinary channels of verbal associations (5).

Hypnosis is a technique that has been used in psychotherapy since the time of Breuer and Freud to help patients recall experiences and feelings that they cannot consciously bring up in treatment. A definition of hypnosis is "that state or condition in which subjects are able to respond to appropriate suggestions with distortions of perception or memory" (19). During the 19th century, the similarities among hypnosis, hysteria (the predecessor of the somatoform disorders, including conversion symptoms), and the presence of early unconscious traumas were detected. Continued evidence supporting the speculation on common processes includes measured hypnotizability, which is above average in patients with conversion disorders, as well as phenomenological similarities between hypnotically induced symptoms. In addition, these findings are a possible rationale for the use of hypnosis in the therapy of conversion disorders (20).

Two broad goals in the application of hypnosis to conversion symptoms include 1) symptom reduction and 2) exploration. Symptom reduction consists of "evoking an elevated level of suggestibility in order to influence the symptoms positively" (20). Although the specific methods used to produce symptom reduction differ, the basic therapeutic principle is the same; "the evocation of a state of ‘trance’ by means of hypnotic induction promotes the suggestibility and can, therefore, prove effective against symptoms that can be influenced by suggestion" (20). The exploratory approach includes techniques such as revivification or age regression, which are used to discover the "cause" of the complaints, possibly followed by symptom-directed suggestions (20). The most famous model for the exploratory approach is the treatment of Anna O. as described by Breuer and Freud (21). In brief, this strategy consists of using hypnosis to evoke memories of a traumatic event that has a causative link with the symptoms. When these patients with conversion symptoms are successfully treated with hypnosis (when their unconscious conflicts, hidden emotions, and forgotten early traumatic experiences are made conscious, processed, and mastered), most of their symptoms disappear (22).

The course of conversion symptoms is variable, as some reactions may be transient (hours to days), while others may linger (3). Chronic conversion disorders can actually produce permanent complications, such as disuse contractures of a "paralyzed" limb that can remain long after the psychic strife of the conversion has been resolved. Although most conversion symptoms remit spontaneously, resolution can be facilitated by insight-oriented, supportive, or behavioral therapy (6, 23). For effective treatment to be possible, the psychiatrist must be aware of the context within which the symptoms have arisen. We hypothesize that the difficulty often found in treating such symptoms results from lack of consideration of these cultural issues.

In sum, conversion symptoms represent a common pathway for the expression of complex biopsychosocial events. Therefore, it is useful to understand conversion from a multidimensional approach in which there are both separate and simultaneous biologic, psychodynamic, behavioral, and sociocultural explanations (6, 9). These theories can be synthesized by using the proposition that conversion represents nonverbal communication of a forbidden idea or feeling. If the capacity to communicate in words is impeded for any reason, an alternative means of expression, such as the somatic language of conversion, may be used (3).

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Sociocultural Considerations

Our point of departure in the analysis of Ms. K is an interdisciplinary method emphasizing the influences of race, religion, and gender in the development of conversion symptoms. The African American woman in America can be viewed as paradoxically both empowered and marginalized by her society and culture. On the one hand, she is very much at the center of her household and church community. Within the family, the African American woman is often not only mother, but also matriarch and de facto head of clan. Within the church, where the female attendance typically exceeds that of males by a significant margin, African American women may find a myriad of opportunities for meaningful work around which many close relationships develop. In this cultural landscape, Ms. K, with her intelligence and industry, found herself drawn to serve in church activities to the point of becoming a minister and community leader.

On the other hand, the position of the African American woman in the United States has often been one of disempowerment. A sense of lack of opportunity for self-realization, especially in emotional and psychological realms, permeates the lives of African American women from a wide variety of backgrounds. Superimpose on this picture the centrality of Christian religion in many of these women’s lives, and the result is very limited space for freedom from obligation and personal demands, as was the case for Ms. K.

While Ms. K experienced this dichotomous identity of simultaneous strength and disempowerment, the centrality of religion added additional complications. For religious persons such as Ms. K, modern living, replete with its assortment of traditionally sinful behavior, demands harsh punishment, strict behavioral regulation, and defined sex roles. Compounding these difficulties inherent in the calling to Christianity, Ms. K, as a church leader, had the additional challenge of balancing her own needs and wants with the obligations intrinsic in her charge to serve others. She and other religious leaders are expected, and expect themselves, to function among sinners without entanglement by their own worldly longing. When facing betrayal coming from their families, church members, or the communities they serve, the commands to stifle unkind words and to stay faithful in service may become oppressive. Anger at having such severe stressors may be turned inward in order to maintain harmony in the group and to avoid the socially intolerable expression of these emotions.

Ms. K was betrayed by her husband, those she served in the mission, and her daughters, and she may well have felt betrayed by her God as well, as he permitted all of these other betrayals to take place. While Ms. K and other religious leaders have been called into a distinguished service, they are still human and may find themselves angry, frustrated, and desiring retribution. However, to seek revenge or to express these feelings would be a sin against the church to which they are devoted. Ms. K had internalized this faith and found herself with no words with which to express or even identify her betrayal.

The literature on conversion disorder suggests that if the capacity to communicate in words is impeded for any reason, an alternative means of expression will be used. For Ms. K, conversion symptoms, manifested primarily in the warping and retardation of speech, became the only acceptable compromise for her to manage these conflicts. Ms. K’s conscious experience was of loving those who had betrayed her most, especially her father, mother, and husband. But her unconscious was the repository of other, less acceptable feelings. We postulate that these feelings pressed toward the surface of her conscious awareness during her trip to her hometown of Miami in mid-June of 1999, when she attempted reconciliations but found herself coldly shut out of her father’s life and insensitively compared to her more successful siblings by her mother. Unable to speak of this terrible experience, Ms. K attempted instead to speak of forgiveness in her sermon to others. Unable consciously to recognize the blow to her self-esteem caused by her parents’ reaction to her, she experienced being "hit" on her head during the sermon, left with an excruciating headache. Whether the onset of her symptoms occurred at that time or later, the "stroke" rendered her dysarthric, her facial contortions physically expressing the anguish, anger, and pain she could not put into words. Her hands, which in her profession were necessarily instruments for helping and healing, now assumed a grotesque, claw-like posture, suggesting an unconscious desire to rip into and tear apart those who had so harmed her in the past.

In the attempts to work therapeutically with Ms. K, several approaches were combined with a partially successful outcome. The initial trial interpretations by the consultation-liaison attending psychiatrist gave a mild degree of transient relief. However, Ms. K refused inpatient treatment at that time, and the only follow-up treatment available to her was once-weekly supportive psychotherapy in which no interpretive work was attempted. This approach was no more successful than had been the directly confrontational approach initially taken by the medical and neurological teams who initially treated Ms. K.

Inpatient treatment offered Ms. K the opportunity to have a trial of hypnosis in a safe, supportive environment. With the partial remission of symptoms as a result of the hypnosis, she began to believe that her symptoms might actually be at least partly psychological. However, even with the support of the hospital and ongoing opportunities to ventilate her feelings about her misfortunes in her inpatient psychotherapy, Ms. K’s symptom relief continued to be only partial.

Conversion symptoms represent a common pathway for the expression of complex biopsychosocial events. Regardless of the theoretical viewpoint regarding the etiology of conversion disorder, the theories can be synthesized by using the proposition that conversion represents nonverbal communication, which can incorporate psychodynamic issues, cultural factors, and learning theory (3). The case of Ms. K demonstrates the important role of sociocultural influences in the development of conversion symptoms. By recognizing the influences of gender roles, religious beliefs, and other sociocultural influences, we can better understand the physical expression of threatening ideas or feelings that conversion symptoms effectively enact.

Presented at Women and Power: Psychoanalytic Perspectives on Women in Relationships, Groups, and Hierarchies, Atlanta, Feb. 25–27, 2000. Received Jan. 17, 2001; revision received April 20, 2001; accepted April 25, 2001. From the Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta. Address reprint requests to Dr. Schwartz, Grady Health System, Central Fulton Community Mental Health Center, 60 Coca Cola Pl., S.E., Atlanta, GA 30303; aschwa2@emory.edu (e-mail).

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Engel GL: Conversion symptoms, in Signs and Symptoms: Applied Pathologic Physiology and Clinical Interpretation, 6th ed. Edited by MacBryde CM. Philadelphia, JB Lippincott, 1983, pp 623-646
 
Bofelli TJ, Guze SB: The simulation of neurologic disease. Psychiatr Clin North Am  1992; 15:301-310
[PubMed]
 
Perley MJ, Guze SB: Hysteria: the stability and usefulness of clinical criteria: a quantitative study based on follow-up period of six to eight years in 39 patients. N Engl J Med  1962; 266:421-426
[PubMed]
[CrossRef]
 
Hollender MH: The case of Anna O: a reformulation. Am J Psychiatry  1980; 137:797-800
[PubMed]
 
Munford PR: Conversion disorder. Psychiatr Clin North Am  1978; 1:377-390
 
McHugh PR, Slavney PR: Hysteria, in The Perspectives of Psychiatry. Baltimore, Johns Hopkins University Press, 1988, pp 223-237
 
Hollender MH: Hysteria: the culture-bound syndromes. Papua New Guinea Med J  1976; 19:24-29
 
Hollender MH: Conversion hysteria: a post-Freudian reinterpretation of 19th century psychosocial data. Arch Gen Psychiatry  1972; 26:311-314
[PubMed]
 
Flor-Henry P, Fromm-Auch D, Tapper M, Schopflocher D: A neuropsychological study of the stable syndrome of hysteria. Biol Psychiatry  1981; 16:601-626
[PubMed]
 
Bendefeldt F, Miller LL, Ludwig AM: Cognitive performance in conversion hysteria. Arch Gen Psychiatry 1976; 33:1250-  1254
 
Orne MT: On the construct of hypnosis: how its definition affects research and clinical application, in Handbook of Hypnosis and Psychosomatic Medicine. Edited by Burrows GD, Dennerstein L. Amsterdam, Elsevier Science, 1980
 
Van Dyck R, Hoogduin K: Hypnosis and conversion disorders. Am J Psychother  1989; 43:480-493
[PubMed]
 
Breuer J, Freud S: Studies on Hysteria (1895 [1893-1895]): Complete Psychological Works, standard ed, vol 2. London, Hogarth Press, 1955
 
Bliss EL: Hysteria and hypnosis. J Nerv Ment Dis  1984; 172:203-206
[PubMed]
[CrossRef]
 
Slator ETO, Glithero E: A follow-up of patients diagnosed as suffering from "hysteria." J Psychosom Res  1965; 9:9-13
[PubMed]
[CrossRef]
 
+

References

Veith I: Hysteria, the History of a Disease. Chicago, University of Chicago Press, 1965
 
Freud S: The neuro-psychoses of defense (1894), in Complete Psychological Works, standard ed, vol 3. London, Hogarth Press, 1962, pp 45-61
 
Ford CV, Folks DG: Conversion disorders: an overview. Psychosomatics  1985; 26:371-383
[PubMed]
 
Farley J, Woodruff RA Jr, Guze SB: The prevalence of hysteria and conversion symptoms. Br J Psychiatry 1968; 114:1121-  1125
 
Somatoform disorders, in Comprehensive Textbook of Psychiatry, 6th ed, vol 1. Edited by Kaplan HI, Sadock BJ. Baltimore, Williams & Wilkins, 1995, pp 1252-1258
 
Lazare A: Current concepts in psychiatry: conversion symptoms. N Engl J Med  1981; 305:745-748
[PubMed]
[CrossRef]
 
Stephansson JG, Messina JS, Meyerowitz S: Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand  1976; 53:119-138
[PubMed]
[CrossRef]
 
McKegney FP: The incidence and characteristics of patients with conversion reactions, I: a general hospital consultation service sample. Am J Psychiatry  1967; 124:542-545
[PubMed]
 
Engel GL: Conversion symptoms, in Signs and Symptoms: Applied Pathologic Physiology and Clinical Interpretation, 6th ed. Edited by MacBryde CM. Philadelphia, JB Lippincott, 1983, pp 623-646
 
Bofelli TJ, Guze SB: The simulation of neurologic disease. Psychiatr Clin North Am  1992; 15:301-310
[PubMed]
 
Perley MJ, Guze SB: Hysteria: the stability and usefulness of clinical criteria: a quantitative study based on follow-up period of six to eight years in 39 patients. N Engl J Med  1962; 266:421-426
[PubMed]
[CrossRef]
 
Hollender MH: The case of Anna O: a reformulation. Am J Psychiatry  1980; 137:797-800
[PubMed]
 
Munford PR: Conversion disorder. Psychiatr Clin North Am  1978; 1:377-390
 
McHugh PR, Slavney PR: Hysteria, in The Perspectives of Psychiatry. Baltimore, Johns Hopkins University Press, 1988, pp 223-237
 
Hollender MH: Hysteria: the culture-bound syndromes. Papua New Guinea Med J  1976; 19:24-29
 
Hollender MH: Conversion hysteria: a post-Freudian reinterpretation of 19th century psychosocial data. Arch Gen Psychiatry  1972; 26:311-314
[PubMed]
 
Flor-Henry P, Fromm-Auch D, Tapper M, Schopflocher D: A neuropsychological study of the stable syndrome of hysteria. Biol Psychiatry  1981; 16:601-626
[PubMed]
 
Bendefeldt F, Miller LL, Ludwig AM: Cognitive performance in conversion hysteria. Arch Gen Psychiatry 1976; 33:1250-  1254
 
Orne MT: On the construct of hypnosis: how its definition affects research and clinical application, in Handbook of Hypnosis and Psychosomatic Medicine. Edited by Burrows GD, Dennerstein L. Amsterdam, Elsevier Science, 1980
 
Van Dyck R, Hoogduin K: Hypnosis and conversion disorders. Am J Psychother  1989; 43:480-493
[PubMed]
 
Breuer J, Freud S: Studies on Hysteria (1895 [1893-1895]): Complete Psychological Works, standard ed, vol 2. London, Hogarth Press, 1955
 
Bliss EL: Hysteria and hypnosis. J Nerv Ment Dis  1984; 172:203-206
[PubMed]
[CrossRef]
 
Slator ETO, Glithero E: A follow-up of patients diagnosed as suffering from "hysteria." J Psychosom Res  1965; 9:9-13
[PubMed]
[CrossRef]
 
+
+

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