Treatment: A miraculous recovery
The pediatrics, child psychiatry, pediatric neurology, and physical medicine/rehabilitation departments treated Miss T. No organic cause of her symptoms was found; results of an MRI with contrast, EEG, and repeated lab tests were negative.
On day 3, Miss T started taking small steps on her own. Two days later, she walked without assistance; discharge was considered.
The hospital’s social services department, however, discovered that the state child welfare agency had investigated Miss T’s family for alleged child abuse/neglect years before but found no evidence.
Also, a school social worker had recently visited Miss T’s family after receiving a complaint that an older sibling was allegedly hitting the younger ones. The social worker noticed that the kitchen door was padlocked; she speculated that the family was struggling financially and did not want the children to eat all the food. No other evidence of child maltreatment was found and the investigation was stopped. None of Miss T’s lab results indicated malnutrition.
The girl was discharged after the mother agreed to allow a home health aide to monitor the children’s well-being and a psychologist to perform neuropsychological tests on Miss T. Follow-up out-patient visits with the pediatric neurology, general pediatrics, and child psychiatry departments were also required.
Conversion disorder: Prevalence and common features
Conversion disorder each year accounts for approximately 22 psychiatric cases per 100,000 overall.3 In the hospital setting, 5% to 14% of medical inpatient referrals for psychiatric evaluation result in conversion disorder diagnosis.3
Conversion disorder is seen in men and women but is more common in young women. Symptoms can occur at any age but are rare in children age < 7 and probably do not occur in children age < 4.3
Prevalence is higher in rural areas and among undereducated and low-income persons.3,4 Researchers also suggest that family history of conversion disorder contributes to symptom onset in offspring.4
The authors’ observations
Once we learned Miss T’s family had been investigated for child neglect, we had to find out if her symptoms were an expression of maltreatment or were caused by psychological stressors at school. Definitive maltreatment never surfaced, and school stress was determined to be a minor factor.
Neglected children exhibit characteristics at different ages that might contribute to conversion symptom development (Table). Most notably, such children have trouble understanding appropriate affective responses to interpersonal situations. As a result, they may express distress in unconventional ways.3
Table
Psychopathology of the neglected child
| Age | Developmental difficulties |
|---|---|
| 1 year | Insecure attachments |
| 2 years | Easily frustrated |
| 3 years | Low self-esteem/self-assertion Impaired flexibility, self-control compared with similarly aged healthy children Difficulty dealing with frustration Lack of persistence, enthusiasm when performing educational tasks |
| Preschool (4-6 years) | Overly dependent Lack of enthusiasm in preschool environment |
| Elementary school (6-12 years) | Attention problems Low self-assertion, self-esteem Withdrawal behaviors, dysphoric affect Social isolation |
| General | Trouble understanding appropriate affective responses to interpersonal situations Limited social problem-solving skills |
| Source: adapted from reference 4 | |
Little empirical evidence supports the link between childhood maltreatment and conversion disorder. In one study:5
- Adults with conversion disorder (mean age 37.6) reported a higher incidence of physical and sexual abuse, more types of physical abuse, sexual abuse of longer duration, and more-frequent incestuous episodes than did adults with affective disorder.
- Among patients with conversion disorder, having a mother with recurrent illness, nervousness or depression, or who abuses alcohol or sedatives was associated with higher dissociative and somatoform scale scores.
- Physical abuse was associated with increased conversion symptoms.
The authors concluded that childhood trauma is a distinct and predictive—though not necessary—feature of conversion disorder.5
The authors’ observations
Psychotherapy and attention to socio-cultural beliefs may enable the patient to “give up” the conversion symptom.3 Several factors determine choices of psychotherapies, although elements of all approaches are commonly used:
- CBT and behavioral therapy have roles in treating acute symptoms.
- Supportive therapy and hypnotherapy are recommended for treating rare, longstanding conversion symptoms (4 to 6 months duration).
- Psychodynamic therapy can help patients who are introspective, can remember details about their past, and are willing to participate in longer-term therapy.
Cognitive-behavioral therapy. Behavior is shaped by what we learn from the environment. Conversion behavior can be reinforced by others who help maintain the symptoms. Behavioral therapy and CBT are aimed at modifying behaviors via desensitization and by increasing the patient’s understanding of his or her physical capacities.
Hypnosis gives patients a medium to recall experiences and feelings they cannot consciously bring up in treatment. Symptom exploration and reduction are broad goals.
Psychodynamic therapy aims to resolve unconscious conflict after a traumatic event. A patient who develops lower-extremity paralysis or sensory problems after having been chastised for running away might benefit from this model, for example.