I would like to take you on a little journey of history and personal reminiscing.

HISTORY

In the early 20^th Century, Freud and other psychoanalysts, who came from a European culture where psychiatry and neurology were closely allied, introduced the concept of the Unconscious Mind and described the many ways in which a person’s life, attitudes and behaviours are influenced by unconscious drives, fears and fantasies. They described psychological defence mechanisms such as repression, denial, dissociation and sublimation that were used to keep unacceptable parts of ourselves out of consciousness. People became familiar with terms such as Freudian Slips and were fascinated by the mind’s ability to dissociate parts of the mind from the rest. The most extreme example of dissociation, Multiple Personality Disorder /Dissociative Identity Disorder, was all the rage and featured as the plot in films such as The Three Faces of Eve, and Sybil.

Freud and others presented cases of motor paralysis or other physical losses of function or senses, which were explained as a loss of function not caused by physical pathology but by an underlying psychological conflict causing a great deal of repressed anxiety, which was unconsciously converted into an apparent physical symptom, thus enabling an escape from the emotional issue producing the psychic pain. That physical symptom would nevertheless provide symbolic clues as to the underlying psychic conflict. 

Because the anxiety would no longer be evident to the patient in a conscious sense, the person would present with a curious lack of concern about their sudden disability – “La belle Indifference”. 

By engaging the patient in psychoanalytic therapy, they could be assisted to allow the underlying conflict to come into consciousness and then be helped to find a more appropriate means to solve it, in a face-saving way, and remove the necessity for the physical symptom.

Thus, was born the diagnosis of Conversion Disorder. The accurate diagnosis relied not only on the presence of a physical or sensory loss with no evident organic basis, but importantly also on the presence also of a symbolic meaning of the physical symptom pointing to the causal underlying conflict which could then be dealt with by psychotherapy.

REMINISCENCES 

In 1965 I was in 4^th year Medicine at Sydney University, seated in a tiered lecture hall in the medical school with my 300 colleagues. Dr John Ellard was an esteemed psychiatrist who headed a large private practice and was a charismatic teacher. On that day he brought along a young woman, aged about 20, who had just recently been referred to him for assessment. She had agreed to come along and be the object of our attention. She was wheeled in, seated in a wheelchair, because she was paralysed from the waist down. She explained that this problem had developed quite suddenly and it presented a problem because she was due to be married. She had no idea why this had afflicted her and with a bit of a perplexed smile said it was a mystery. She was curiously bland and showed no distress.

Dr Ellard then had her taken from the room and told us the information that he had gleaned. The young naïve woman came from a middle eastern family, immigrants to Australia with very strong cultural beliefs.  Her father was a very strict, religious man who made all important decisions for the family. He had promised his daughter in marriage to a man not much younger than himself, whom she barely knew. The father would brook no dissent in the family. The young woman dreaded the idea of marrying this ugly old man. She could not possibly face the possible consequences of marrying him, but also could not refuse, as that would result in her being disowned by her father and ostracized by the rest of the family. In the days before the wedding, she discovered she could not walk. She could not walk anywhere and it was evident to all that she certainly could not walk down the aisle. The marriage ceremony had to be cancelled and Dr Ellard’s task was to assist the patient to consciously experience her repressed emotions and also to deal with the family, in regard to allowing her some acceptable path out of both the real issue and the great psychological conflict that it had produced. He explained that this was a classic case of Conversion Disorder.

About 14 years later, I was a young psychiatrist working in the newly created Department of Psychiatry at the Flinders Medical Centre in Adelaide. As part of my duties, I was doing consultation-liaison work with the Neurology service. I was asked to see a 19 year old man with a curious presentation. About 2 weeks earlier he had been brought by ambulance to the emergency department with apparent quadriplegia. He had been behaving recklessly at a roller skating rink and had a huge tumble, and then was paralysed and taken urgently by ambulance to hospital. 

The neurology registrar was very concerned by what he found and urgent admission was arranged.

Investigations showed no fractures. Neuroimaging was in its infancy; CT scans were fuzzy and there was no MRI. Over a couple of days, the paralysis resolved. It was postulated that there might have been an acute flexion injury causing a reversible concussion of the spinal cord. The patient was discharged.

About two weeks later, the patient was brought to emergency once more, with a repeat of the same story. He had been skating again, had a big tumble and was again left paralysed. This time, the signs were not as convincing. The perceptive neurology registrar noted in the file that the patient was “exhibiting psychiatric behaviour”. I gathered that meant that the young man had shed a few tears.  

I was asked to see him.

Initially, the young man gave a fairly matter-of-fact history and said he could not understand what was happening. He was regaining some movement and was keen to leave hospital. At first, he was not really engaging in the interview. However, with gentle persistence I explored his life, family and social relationships and asked about any recent events in his life. He lived with his father, a single parent who set high standards, expected a lot from his son and could become very angry at times. The son loved his father but dreaded his disapproval. 

After quite a long time, as I was exploring his social network, the patient hesitantly told me that one of his closest friends was in a spinal injury unit after recently becoming quadriplegic. He had yet to visit his friend after the injury. With a lot of encouragement, he went on to tell me of the circumstance of his mate’s injury. A group of them had been down by the Murray river, skylarking on top of a cliff, several meters above the water. A couple of friends had jumped in, but his mate didn’t want to. The patient was daring his mate and then actually pushed the mate off the cliff. To the shock of everyone, the mate floated to the surface, paralysed. Friends dragged him to the bank and eventually he ended up in hospital having surgery on his cervical fractures, but remaining permanently quadriplegic.

My young patient was appalled by what had happened but it appeared he went into an automatic state afterwards. He had gone on with his life and apprenticeship and had put the incident out of his mind. He hadn’t mentioned it to his father.  He also had not contacted or been to see his close friend in hospital.

As he talked about all this he began to sob. He was intensely guilty for what had happened and for his role in causing the injury. He hadn’t been able to tell his father, for fear of the intense disapproval he expected would come his way. He feared alienation from the father he both loved and feared.

I followed that assessment by facilitating a joint interview between the young man and his father. It was an intense relief for the son when his father was surprisingly understanding and supportive. Their bond was clearly going to be healthier and stronger after this experience.

Very soon after this process, the patient completely recovered. He decided he would soon go to see his mate. He left hospital with an offer of follow-up, but we never saw him again.

This was an unusual example of an acute conversion disorder, which responded dramatically to exposing the symbolism of the symptoms he had presented with.

DIFFERENTIAL DIAGNOSIS

There are traps for the unwary in making a diagnosis of conversion disorder in a situation where no physical evidence of disease is evident, but also no evidence of unconscious psychological conflict. Decades ago, there was a celebrated research publication that came out of the Queens Square Neurological Hospital in London. A sizeable cohort of patients who had been diagnosed as having conversion disorder were followed up after a lapse of 5 years. The study showed that at least two thirds of those patients had eventually been diagnosed as having a variety of neurological disorders, many with multiple sclerosis.

A dramatic example of such a potential trap was in another case I saw at Flinders Medical Centre. A woman was being delivered of an infant after an apparently normal pregnancy. She had had little prenatal attention in her small rural town but there was no reason to expect her child would be deformed. These were the days before the use of ultrasound in pregnancy. As the child was delivered, the mother heard a junior nurse say “Oh No” in a horrified way. A pillow as raised to shield the baby from the mother’s view. There was a shocked silence and the baby was immediately removed from the delivery room. The child was anencephalic, with no brain or skull structure above the forehead.

The attending staff then broke this dreadful news to the mother. She was told the infant would not survive more than a day or two.  She was, of course, shocked and distressed. She refused an offer to see the baby.

She went to her room and as the day wore on complained that she had a severe headache and then she completely lost all vision. She was suddenly completely blind. The immediate thought was that the trauma of the birth had caused her to lose the ability to see her child and that this was a case of conversion disorder, with the blindness being an unconscious protective mechanism against experiencing further emotional trauma. I was called to see her.

This theory was indeed a tempting one, but there were some difficulties with the way she was presenting. She did not have La Belle Indifference. The blindness was not protecting her from her grief. She was very confused and upset by it, and it was just adding to her distress as to what was going on. There was also the fact of the severe headache. She had a history of migraine.  Further investigation was needed. A CT brain scan was conducted. While the quality was primitive by today’s standards, there was no doubting the pathology that the scan revealed. She had completely infarcted both occipital lobes. A massive basilar migraine, triggered by the enormous stress of the birth, had rendered her blind. I believe she never recovered her vision. 

This case taught me the folly of jumping too quickly to a glib diagnosis of a psychiatric disorder without a thorough examination of all the facts and the potential differential diagnoses.

The other important differential diagnosis when conversion disorder is one possibility, is that of a factitious disorder or malingering, where a physical symptom is not the result of unconscious processes but, rather, a conscious simulation of illness for some kind of gain or manipulation of others. This gain would be called secondary gain by Freud, distinguishing it from the primary gain of solving an unconscious intrapsychic conflict.

 When I was a junior resident at Sydney Hospital in 1968, the eminent physician Allan McGuinness demonstrated his way of diagnosing and dealing with such a patient. A physician in Canberra, a former protégé of Dr McGuinness’, asked for help with a puzzling patient. She was a trained nurse, aged in her thirties, married to a prominent Canberra clergyman, and had presented with an odd constellation of symptoms, including haematuria, passing of renal calculi, and recurring seizures.

She was admitted to the medical ward and investigations commenced. Ward testing showed blood in her urine. She was asked to urinate into a pan and some small dark stones were found in her urine. 

I was part of the retinue that attended her bed with Dr McGuinness and the senior registrar. While talking to the patient, she began to fit, apparently becoming unconscious, with quite convincing tonic and clonic movements. Some meaningful glances were exchanged, the registrar stroked the bottom of her feet and the Babinski reflex remained normal throughout the seizure.

 Over the next day or two, some more seizures occurred and a range of tests were completed. A surreptitious search of the patient’s belongings had discovered the presence of a urinary catheter and a blood stained syringe. 

At the next ward round Dr McGuinness was very direct with the patient.

“Now, young lady, I want to have a word with you”.

“Yes, doctor”

“Those fits you’ve been having.”   “Yes, Doctor”.

“They aren’t real fits…. You won’t have any more, will you?”.

“No, Doctor” – looking embarrassed. 

“And those stones you’ve been passing”. 

“Yes, Doctor?”.

“They’re not from your kidneys… The pathology report says they are asphalt. They’re from the road! You won’t pass any more, will you!”.  

“No, Doctor”.

“You will be going home tomorrow. I will be in touch with your doctor”. 

And with that, the ward round retinue moved on to the next patient.

I was already pretty sure by then that I wanted to do psychiatry and I was gobsmacked that there was no apparent curiosity shown as to the motivation for the patient’s factitious behaviour; no apparent thought about asking for a psychiatric consultation or even involving a social worker. Of course, there was no way as a junior resident that I could do anything. I was left to hope that when Dr McGuinness spoke to the referring physician, there would be some suggestion of appropriate follow up, investigation and meaningful management. While this was a case of conscious deceit and manipulation by the patient, the hoped-for gain was unclear and, without proper exploration, there would be no clarity or cure for the underlying motivation.

Over the decades since I had those early experiences, I have only rarely seen what I would regard as a case of true conversion disorder. It is quite likely that such cases are still seen in neurology practice. I hope, if this is the case, psychiatrists are still involved in their management. But my impression is that with the massive changes in psychiatry over the last half century, this may not always be the case. 

Nobody talks much about the unconscious mind any more. Psychoanalytic theory and practice are out of fashion. The huge advances in the understanding of brain biochemistry and function have radically changed how patients are treated. Psychotherapy has mostly become based primarily on behavioural psychology, brief cook-book recipe therapy is now delivered more by psychologists than psychiatrists, psychiatrists increasingly being expected to prescribe rather than to indulge in talking to patients or diving into their unconscious thoughts and conflicts. 

The diagnostic classifications we now use are firmly descriptive and deliberately theory-free. This reflects the territorial war that went on in the USA, between the powerful psychoanalytic school that had ruled the roost for so long, and the neurosciences school now dominant.  So, we are unlikely to label a patient as having conversion disorder.  More likely, they will be classified by a neurologist as Functional Neurological Disorder, or described by an orthopaedic surgeon as exhibiting Abnormal Illness Behaviour, or even just Illness Behaviour. These are terms which give no clue as to the underlying psychological and emotional origin of the symptoms and signs.

It is possible that with increasing mental health literacy in our societies, there is now more ability for us to express feelings and resolve emotional issues that we may suffer, with less need for the rather coarse resort to conversion as a mental strategy.  But it is quite likely that true conversion disorder remains more likely in less sophisticated people in society, in third world countries or in rigid conservative cultural groups within our own society.

I have heard said, after I revealed the title for this talk, that nothing has happened to conversion disorder – that the Leximed waiting room is full of such patients. I would politely say that that is not the case. What we do tend to see in medico-legal practice are patients with real physical disorders, with additional overlying or complicating emotional and psychological factors. There may be disagreement about the physical diagnosis; there may be expectations of how the recovery process should proceed, and any deviation from the doctor’s expectations may cause suspicion about the motivation. But it is rarely a cut-and -dried matter of being all in the mind.

An injury occurs in an individual with their own predispositions, life experiences and susceptibilities. Pain and reaction to injury will be perceived in all sorts of different ways, depending on the particular individual’s background vulnerabilities.

 Not uncommonly, a person with a complicated family and social background may grow up with a shaky self-esteem and self-concept. They may compensate for that by building up their body, using physical activity and sporting prowess to feel more confident and acceptable to others and themselves. Their social network may be totally oriented around physical activity and sport. A physical injury that takes away these possibilities can therefore be devastating and life-changing, with emotional consequences being out of proportion to the average expectations for physical recovery. Pain and emotions have a complex interaction. 

The bland description of a theory-free diagnosis falls short of explaining the psychological and emotional factors that are very relevant to a proper assessment and complete management. Often, more than one medical specialty needs to be involved to explore the total picture.

There may, of course, also be elements of conscious manipulation and the seeking of gain. The gold at the end of the compensation rainbow may be very tempting. In my own clinical experience, pure factitious disorder is not very common and generally fairly readily recognised for what it is through a comprehensive assessment, often with multi-specialist input. Or maybe I just don’t get to see such patients. Or maybe I’m too gullible. More likely and more frequent, I believe, is the conscious exaggeration of a true disability from some physical or emotional trigger. Occasionally, collateral evidence such as video may be helpful, if one is cautious about interpretation of such evidence, particularly from a psychiatric perspective.

Medical practice these days tends to be time-poor. A medico-legal assessment can only go so far in carrying out a complete assessment. Accessing a thorough process of biopsychosocial investigation and treatment is difficult. We can only do our best, trying to approach our patients with an open mind, and gaining some idea of the potential complications that are affecting their lives after they have suffering an injury or an emotional breakdown.

So, is it Vale Conversion Disorder?  Maybe. But not completely. I have fond memories of it. I miss it, as a clinician. Nowadays, our clinical lives tend to be more complicated and nuanced in regard to how our patients present. We must try to adapt.