Conversion Disorder: Its History and Implications

Of all conditions treated in our field, perhaps none more clearly demonstrates the need for a dynamically-informed psychiatry than conversion disorder. The patient who presents with neurological symptoms without identifiable neurological cause has long perplexed nonpsychiatric physicians and psychiatrists/psychoanalysts alike. It is the problem that got Freud interested in examining the role of the unconscious, and I contend that its understanding can yield greater insight into the nature and treatment of mental illness.

Conversion disorder, previously referred to as "conversion hysteria" and later as "conversion reaction," is classified by DSM-5 as a somatoform disorder and by ICD-10 as a dissociative disorder. The newer term "functional neurological symptom disorder" was introduced as a subtitle in DSM-5—a change representative of the shift away from dynamic and towards descriptive definitions of mental disorder.

While recent attempts have been made to utilize functional neuroimaging to identify the biological mechanisms underlying conversion symptoms, the conceptualization of conversion disorder still rests heavily on Freud's original model. In fact, it has been said that the entire development of psychoanalysis as a field of study and form of treatment for mental disorder is based on Freud's study of conversion under the tutelage of Jean-Martin Charcot in 1885-86 (Bogousslavsky & Dieguez, 2014).

From an analytic perspective, conversion disorder represents a complex unconscious attempt on the part of the patient to resolve an internal psychological conflict (Brenner, 1955). Unable to express himself via conventional means, the patient resorts to a somatic protolanguage as a method of communication. As a rule, the patient does not acknowledge the hidden meaning of his symptoms which are driven by forces outside of his awareness. The treatment of such a condition rests on the careful interpretation of the symptoms as a symbolic form of expression and gently encouraging the patient to communicate more freely and directly.

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 cause 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 who resorts to conversion is symbolically expressing an internal psychological conflict, there appears to be less interest in examining the other forms of psychopathology as symbolic methods of communication—outside of psychoanalytic circles.

The positive symptoms of schizophrenia, for instance, can be interpreted as symbolic concretizations of abstract ideas, wishes, and conflicts (Arieti, 1974). The paranoid patient with a history of trauma and abuse may come to believe, for example, that an authoritarian or draconian government regime, symbolically representing his abusers, is targeting him. Similarly, the depressed patient may utilize his depression as a means of expressing the emotional pain and harm inflicted upon him by others. In both of these cases, the symptoms are not mere manifestations of disease but rich, symbolic representations of unconscious or unacknowledged material—ripe for analytic interpretation and understanding.

I propose using the psychodynamics of conversion disorder as a conceptual model for understanding the broader range of conditions that fall under the psychiatric domain. Our patients are telling us something with their symptoms. Their suffering is not mere consequence of biological abnormality (though it is becoming increasingly clear that biology is at play) but rather a very complex and intricate means of relaying to us their feelings, wishes, and emotional conflicts. The successful treatment of psychiatric disorder, then, rests not only on the alleviation of observable symptoms but also on a decoding and deciphering of the patient's hidden message.

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The symbolic nature of a patient's symptoms, demonstrated most clearly by conversion disorder, is what separates psychiatry and psychotherapy from neurology—and it should be recognized and embraced as the defining feature of the human conditions we treat.