Indian Pediatrics 2002; 39:747-752
Clinical Characterstics and Outcome of Children and Adolescents with Conversion Disorder
Prahbhjot Malhi Pratibha Singhi
Conversion disorder is a loss or alteration in sensory or voluntary motor function that cannot be fully explained by known pathophysiological mechanisms. In addition, the symptoms must be closely associated with a significant psychosocial stressor(1). Conversion disorder excludes symptoms that can be fully explained by a general medical condition, substance abuse or culturally sanctioned behavior. Presenting symptoms are unintentional and may resemble a neurological dysfunction including paralysis, tremors, gait disturbances and pseudo-seizures(2-4). These symptoms may cause more distress among parents and clinicians than to the patient, also referred to as la belle indifference(5).
Taylor(6) has postulated that the child with a conversion disorder is faced with an inescapable, intolerable predicament and relief is provided in the form of an illness. The illness is promoted by an ally, either parents or physicians. In addition, the child must have adequate social skills in order to enact out the symptoms which correspond more to the child’s idea of the physician’s conceptions of physical illness. Maisami and Freeman(7) have argued that conversion reactions in children are a form of body language, which represents the child’s plea for help in situations where the child is unable to cope.
Conversion disorder among children is a relatively rare condition in the developed countries(8) but several epidemiological and clinical studies conducted in India have found the condition to be very common(9,10) with a prevalence rate as high as 31% among inpatients admitted to Psychiatry department(11). Conversion disorder is more common in girls than boys(2,3,10).
The diagnosis of conversion disorder in children is at times difficult as well as risky. A major pitfall is the high incidence of organic disorders that are subsequently diagnosed which in retrospect can explain the initial symptoms. The incidence of previous medically identifiable illness ranges from a low of 10% to high of 60%(3,12). Atypical presentations of uncommon neurological disease may also be wrongly labelled as conversion disorder. Another diagnostic problem is one in which there is a true organic disorder involving the same organ as part of the body in which there is a superimposed conversion reaction. Even when the diagnosis is made, parents, families and the child may disbelieve it and actively resist psychological treatment approaches.
Given the nature of the disorder, it is reasonable to assume that the disorder would be common in pediatric settings. However, little is known and reported in the literature about the profile of children and adolescents seen in pediatric settings. Keeping this in view, the aim of the present study is to describe the clinical characteristics and outcome in children with conversion disorder.
Subjects and Methods
All children with a clinical diagnosis of conversion disorder referred to the Psychology Services of the Department of Pediatrics at Post Graduate Institute of Medical Education and Research during a one-year period (May 2000 to April 2001) were recruited for the study. A detailed clinical examination including neurological evaluation was done by a pediatrician. In addition, appropriate investigations including EEG, CT Scans were performed to rule out any underlying organic etiology. Two children with a chronic illness were excluded. Detailed psychosocial evaluation of the children was done by a child psychologist. This involved eliciting a detailed history of recent interpersonal problems with school, teachers, peers, siblings and parents, a possible temporal relationship between a specific stressor and onset of symptoms, existence of a symptom role model, symbolic meaning of the symptoms for the child, secondary gain from the symptoms and assessing the child’s concern for the symptoms.
Sixteen children meeting the diagnosis of conversion disorder as per the DSM (IV) criteria(1) were recruited in the study. The children were jointly managed by the two authors (a pediatrician and a child psychologist) in the Department of Pediatrics. The treatment and management of children with conversion disorder generally followed the approach highlighted by previous authors(7,13-14). This involved (i) shifting the focus of the parents from an organic to a psychosocial explanation of the symptom; (ii) encouraging the child and parents to resume normal activities; (iii) ignoring or discouraging sick role behavior and positively reinforcing coping and return to healthy behavior; and (iv) using problem solving coping techniques to tackle child’s difficulties and family counseling for enhancing parental competence to tackle problems and family crisis resolution. The outcome of treatment was determined by the presence or absence of the original symptoms and clinician’s impression regarding the parents and child’s insight into the etiology of the problem and its manifestation. All children were followed upto a period of 3 to 6 months after the initial diagnosis was made.
The mean age at presentation was 11 years with a range of 8.2 to 14.6 years. Only 2 children were younger than 9 years and none below 8 years. The female: male ratio was 1:1.6. Most children were from urban areas (62.5%) and were living in nuclear families. The mean socio-economic index was 3.4 which indicates a low middle class family with an average monthly income of Rs. 5950. Education among parents was low and mothers and fathers had on an average completed 6.6 and 9.8 years of schooling, respectively. Children were generally from large families and had on an average 2.27 siblings (range of 1 to 5) with 1.9 sisters and 1.3 brothers.
Pseudoseizures were the most common presenting symptom present in 10 of the 16 children. Atypical pseudoseizure was characterized by the child complaining of giddiness followed by a fall on the ground and irregular bizarre movements of the limbs for a duration of 3 to 5 minutes. The child would then recover and resume normal activity. Usually the child would have several attacks in a day. Besides pseudoseizures these children also complained of other somatic symptoms including headache, weakness, giddiness, and abdominal pain. Other conversion symptoms included fainting spells (4 children), weakness of legs accompanied by bizarre gait characterized by non rhythmic gait with instability not confirming to any neurological abnormal pattern (1 child) and asphasia (1 child). Majority were incapacitated by their symptoms and were either not attending school (n = 8) or attending school intermittently (n = 6).
Thirteen families reported significant and multiple psychosocial stresses. Among the stresses the most common were school difficulties and pressure from parents to excel academically. Family related stress was also common. Four families reported serious marital discord, tension and conflict at home; physical abuse of mother and child were reported by two families and abuse of alcohol by father by one family. Sibling rivalry and lack of affection and attention at home was admitted by two children. Recent financial stress due to either loss of job, losses in business or legal battles were reported by the families of three children.
A role model was reported by 6 (37.5%) children. For example, two children had witnessed a seizure of a classmate at school, and one child’s father had suffered a paralytic stroke and was confined to bed. Five (31.3%) children were not concerned about their symptoms although their parents and relatives were extremely distressed.
Regarding duration of illness, 4 children had their symptoms for more than 3 months but less than 6 months, 6 children for more than a year and 4 for less than three months. Before being referred for psychosocial evaluation with a diagnosis of conversion disorder, children had been seen by other physicians, including neurologists. All the children who had the symptoms for more than a year had been seen by several physicians and had undergone multiple clinical investigations like EEG, CT scans, X rays, blood tests. All investigations were normal and not indicative of any underlying organic condition. Some children with pseudoseizures had been started on anticonvulsant therapy with no relief in symtomatology. A pronounced feature of the parents of children with symptoms of a longer duration was anger directed at the physicians for not having treated and managed their child adequately.
Four (25%) children recovered from their symptoms within 6 weeks of the initiating of treatment and five (31.3%) had recovered within 3 months. Four (25%) families withdrew from treatment before the psychosocial problems could be completely explored and did not come for follow up. Two (12.5%) children showed some improvement in symptomatology. All children who showed improvement resumed normal activities, were attending school regularly and had shown no recurrence and there was no single instance of symptom substitution during the entire period of follow up (3 to 6 months).
Several studies reported from India have documented that children with conversion disorder form a sizeable proportion of cases seen in Child Guidance Clinics(9-11). Although ours is not a prevalence study, 4.13% of children referred to psychology services of the Department of Pediatrics of a tertiary care hospital were diagnosed with conversion disorder. It has been argued that in cultural setting, such as ours, where expression of emotional distress is generally discouraged, having a physical condition is the most acceptable means of seeking help or expressing psychological distress(11). The socio-economic and demographic character-istics of the sample were generally in agreement with other studies. All children were above 8 years and majority above 10 years. These results support previous observations that conversion disorder is rare in very young children(5). Taylor(6) argued that conversion symptoms can only be enacted by persons with adequate social skills and therefore, the diagnosis of conversion disorder in young children should be made with great care. Several studies have documented that hysterical conversion reaction is more prevalent among females than males(2-3,11). We found a slight preponderance of males in our sample. Possibly since ours is a referral center in North India, a region well known for a strong preference for sons(15), parents may be more likely to seek treatment for their sons rather than daughters(16).
Psychosocial stress among the children and families mainly related to school and family problems. Academic difficulties, school failure, pressure from parents to excel were commonly cited school problems. There was a close temporal contiguity between school exams and onset of symptoms. Conversion symptoms may allow a child with academic difficulties to avoid failure at school, with academic problems serving as both a continuous stressor as well as a perpetuating factor(17). Several studies have documented a close association between psychosocial stress and conversion symptoms. For example, Maloney(18) in a retrospective study of 105-inpatient children with a diagnosis of hysterical conversion reaction found a high frequency of recent family crisis, unresolved grief reactions and family communication problems. Srinath et al(11) reported significant stressors among 71% of children with hysterical conversion reactions in a study from India. Some of the stressors reported included punitive parent, financial difficulties, parental disorder, sibling rivalry, academic difficulties and adjustment problems with peers.
A role model in the child’s social milieu was identified in only one-third of the cases studied. This relatively low figure may be due to the difficulty in eliciting the same. Taylor(6) argued that the model may be current or arise from the long forgotten past, real or imagined and may also evolve during the course of the illness. Previous studies have also documented that role model of the illness may not always be present. Moreover, the lack of concern by the child for the symptoms was also not seen among all patients. It is important to keep in mind that la belle indifference is not invariably seen in patients and in one study was reported in as few as 8% of cases(12). Although there are several features which help in making a positive diagnosis of conversion disorder in a child, all the characteristics might not be found in a single patient(2-3,5).
A striking feature of the results of the study was the rapidity with which the symptoms resolved once the diagnosis was made. Majority of the patients recovered within one to three months of the initiation of therapy. In fact, once the symptoms disappeared, families showed more commitment to therapy. Symptoms resolution further helped the families to accept the validity of the diagnosis. Previous studies have documented favourable outcome in children with conversion disorder. For example, Bangesh et al(19) reported that all the seven children with hysterical conversion reaction recovered or began recovery within a few days of diagnosis and none of them had a relapse within 3 to 11 months of follow up. Leslie(2) found that 17 of the 20 children with conversion reaction had recovered completely within three months of starting treatment. Our short term follow-up ranging from one to six months indicated that most children had recovered and there was no recurrence or substitution of new symptoms. However, it remains to be seen how these children fare over a longer period of time. Moreover, given the small sample size of the study, some caution in generalization of the findings is warranted.
The study highlights the importance of a team approach between the pediatricians and psychologists in the diagnosis and successful management of children with conversion disorder. Collaborative management not only reduces the risk of missing an organic etiology by wrongly labeling a child’s illness as functional but at the same time involvement of mental health workers at the earlier stages of diagnosis helps in avoiding unnecessary medical tests which further entrench the sick role. Longer follow up would further ensure whether the gains from therapy are sustainable.
Contributors: PM coordinated the study, designed it, collected the data and drafted the paper, she will act as the guarantor for the manuscript. PS helped in designing the study and drafting the paper.
Funding: Postgraduate Institute of Medical Education and Research, Chandigarh.
Competing interests: None stated.