“… for all the shortcomings in the concepts proposed by Freud and Breuer in Studies [on Hysteria], the 21st century has brought no great advances to a better understanding of the mechanisms for this disorder.” – Dr. Suzanne O’Sullivan, It’s All in Your Head (2015)
Conversion disorder represents perhaps the most inherently fascinating of all psychiatric conditions. A seemingly healthy individual, often in the prime of his life, is struck down by debilitating neurological symptoms—rendering him unable to walk, talk, or move a body part. After a thorough medical and neurological workup, no organic cause can be detected. The problem is not with the body, it is with the mind.
Previously referred to as conversion hysteria and later as conversion reaction, conversion disorder has long baffled patients and doctors alike. It is the problem that more than a hundred years ago led Freud to investigate the role of the unconscious and develop his new art of psychoanalysis, forever changing the course of psychiatry and medicine. I contend that its understanding can yield greater insight into the nature and treatment of the human problems called mental disorders.
Jean-Martin Charcot demonstrating hysteria in a patient at the Salpêtrière hospital, 1887.
My experience is that most biological psychiatrists have neither interest nor knowledge in working with patients with conversion disorders, and most acknowledge that while drug therapy can temporarily mask or alleviate suffering, it is not really treating the underlying mental disease. Similarly, cognitive behavioral therapists and others trained in the now popular short-term therapies seem to know little about how to work with such patients. Teaching the patient the irrationality of his beliefs or intoxicating him with a benzodiazepine does nothing for the conversion disorder patient.
The treatment of choice for conversion disorder is psychoanalysis or psychodynamically-informed psychotherapy. From an analytic perspective, conversion disorder represents a complex unconscious attempt on the part of the patient to communicate a message. Usually, the person is unable to or prevented from communicating the message via traditional means, and, as a rule, the patient does not acknowledge the hidden meaning of his symptoms. The treatment of such a condition rests on the careful interpretation of the symptoms as a somatic protolanguage and gently encouraging the patient to express himself more freely and directly.
Every effort should be made to enlist the help of a neurologist to explain to the patient the reasons why his condition is not due to organic disease of the nervous system. Sometimes it is helpful for the patient to be assured by several medical doctors that the problem is not physical. However, once a diagnosis of conversion is made and organic disease has been thoroughly excluded, the treating clinician must be steadfast in his psychological approach to the patient’s condition. To waver on this issue is to do the patient a grave disservice.
I am reminded of a case of conversion disorder I saw a few years ago while in practice in North Carolina. A young woman, a Marine recruit who came from a long line of Marines in her family, had recently finished her basic training. When she received her Marine Corps job assignment (MOS), it did not align with what she had planned—and what her family had hoped.
Suddenly, she became paralyzed from the waist down and was confined to a wheelchair. Interestingly (and symbolically), she was able to walk backwards but could not stand or walk moving forwards. After several thorough neurological workups, no organic disease could be detected. She was diagnosed with conversion disorder and referred for psychoanalytic treatment. Unable to express her discontent verbally within the strict confines of the Marine Corps, she resorted to a somaticized protolanguage—a language comprised not of words but of pseudoneurological symptoms. Like many conversion disorder patients, she demonstrated no worry over the debilitating nature of her symptoms—a phenomenon labeled la belle indifference, from the French, “the beautiful indifference”.
While it is generally accepted that the patient with conversion disorder is engaging in a pathological method of communication, there appears to be less interest in examining the other forms of psychopathology as symbolic methods of communication—outside of psychoanalytic circles. Schizophrenia, depression, obsessive-compulsive disorder, eating disorders and others can all be interpreted as symbolic representations of unconscious or unacknowledged conflict—ripe for psychoanalytic understanding.
Silvano Arieti (1974), the renowned Italian American psychiatrist, pointed out how the positive symptoms of schizophrenia are symbolic concretizations of abstract ideas, wishes, and conflicts. Other psychoanalytic theorists have advanced similar understandings of the other psychiatric disorders.
But it is conversion disorder that most clearly demonstrates the need for psychodynamically-informed practice. While the condition can be difficult to treat and patients sometimes unwilling to devote themselves to the psychological work necessary to get better, an understanding of the nature of conversion disorder is paramount to its treatment—and can yield greater insight into the problems treated by psychiatry more generally.
Over one hundred years after Freud first developed his groundbreaking theory, there remains no better understanding of conversion disorder than that offered by psychoanalysis, a testament to Freud’s enduring genius and the continued need for a psychoanalytically-informed psychiatry.
Image: Jean-Martin Charcot demonstrating hysteria in a patient at the Salpêtrière hospital, 1887.
Arieti, S. (1974). The interpretation of schizophrenia. New York, NY: Basic Books.