November 14, 2016

They call it a conversion disorder

Dear Bloggers,

The recent discussion between me and the caretakers of my spouse are a difficult case and is leading to speculation and misinformation about the nature of psychogenic illness. I therefore thought it would be useful to discuss the concept of a conversion disorder in general.
 
According to one of the doctors who tried to explain me about dealing with the disbelief of most of the patients they react many times like this: “So you’re telling me it’s all in my head?”



The concept of what are now called conversion symptoms is a tricky one for various reasons. There is an unfortunate stigma attached to the notion that our brains can cause physical symptoms. Making the diagnosis is complex. Outcomes are variable and are hampered by the difficulty in communicating the diagnosis to patients. Conversion disorder symptoms often mask underlying physiological disease. And the risks of both false positives and false negatives are high.

This complexity leads some to argue, in essence, that a conversion disorder symptoms do not exist at all. The diagnosis is tricky as the patient might feel it like a way to blame the patient for the failings of the physician.
What are conversion disorder symptoms?


Various terms have been used over the years to refer to symptoms that are generated by psychological stress or other factors. Hysteria is an unfortunate term which was invented to refer to the uterus, as if such symptom were uniquely female. For obvious reasons the term “hysteria” is no longer used. 

Psychosomatic is still a proper term, meaning physical symptoms with a mental cause, but the term does have a bit of a stigma attached. The term conversion disorder is most widely used today, or psychogenic simply meaning having a mental cause.


As my wife has been diagnosed with complex PTSD with anxiety related problems and has a psychogenic overlay. In this case there is an underlying physiological disease or disorder which then results in stress and anxiety which further generates the conversion disorder symptoms on top of the physiological symptoms. 
 

Psychogenic signs and symptoms are real the patient really experiences them. A conversion disorder is a real disorder, it is just that the problem is with the brain’s software, not hardware.

Sometimes my wife is overtaken by her anxiety disorder, which may be reactive or may be primary and due to a biochemical disorder in the brain. Anxiety puts a lot of stress on the body and can absolutely manifest with physical, and sometimes very dramatic, symptoms. Stress itself can also manifest with physical symptoms. My wife is living like she is constantly being scared with very hectic moves


So we all have psychogenic symptoms at some point in our lives, and we take them for granted. The fact that more dramatic symptoms can also result from purely psychogenic causes should not be that surprising.
How do we known when symptoms are psychogenic?


At times patients will have psychogenic weakness, either partial or complete paralysis of a limb. This happens to my wife when the tension gets to high at that moment she loses power in her right hand and she is dragging one leg around. The first times I was very worried and thought she was having a stroke as she didn't feel her face on one side as well.True neurological weakness has certain features which cannot be simulated (voluntarily or involuntarily) and there are techniques they use in the neurological exam to look for these features. And strange enough there was nothing found.


Further still, without a detailed knowledge of neuroanatomy, patients with psychogenic symptoms will tend to display distributions of symptoms that do not follow anatomical pathways. Or they will display patterns of movements that do not correspond to any part of the motor system.

To summarize, there are cases in which patients exhibit neurological symptoms which seem to defy neuroanatomy, reveal features of effort, do not correspond to known systems in the nervous system, and lack any hard or objective finding that should be present. Even in these cases, they're likely to do a full workup looking for an underlying problem (as stated above, psychogenic symptoms may simply be overlaying a physiological lesion or disease). In psychogenic cases thorough neuroanatomical scans are normal, as are physiological tests for nervous system function.


It is not a negative judgment about the patient, it is simply an attempt to make an accurate diagnosis.

Sometimes patients are simply uncomfortable with this situation (perhaps because it was not communicated to them well). They may seek a diagnosis until they find someone willing to make one, and then they will blame their previous doctors for “missing” the real diagnosis. Sometimes the actual diagnosis is missed, and patients were right to seek other opinions. But at other times the new diagnosis is the fake, but it is more acceptable to the patient than the stigma of stress or anxiety induced symptoms.


It should also be pointed out that sometimes there is an underlying disorder causing psychogenic symptoms – serious anxiety or depression. These are just as much “real” disorders as anything else.

Patients who have disturbing symptoms due to psychological stress or anxiety will often seek multiple opinions.
In some cases the patient has what can only be called mental illness, and needs to be redirected toward psychiatric treatment.


Conclusion

In a perfect world the unfortunate stigma attached to the psychogenic and conversion disorder diagnosis would disappear. It is very counterproductive. We need broader understanding that the brain is also an organ and can manifest symptoms in a variety of ways. Psychogenic causes are just another item on the differential diagnosis.

The Old Sailor,