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Psychosomatics 50:50-58, January-February 2009
doi: 10.1176/appi.psy.50.1.50
© 2009 Academy of Psychosomatic Medicine
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The Prevalence of Conversion Symptoms in Women From a General Turkish Population

Vedat Sar, M.D., Gamze Akyüz, M.D., Orhan Dogan, M.D., and Erdinç Öztü, Ph.D.

Received January 2, 2007; revised May 1, 2007; accepted May 18, 2007. From the Clinical Psychotherapy Unit and Dissociative Disorders Program, Dept. of Psychiatry, Medical Faculty of Istanbul, Istanbul University, Istanbul, Turkey. Send correspondence and reprint requests to Vedat Sar, M.D., Istanbul Tip Fakültesi Psikiyatri Klinigi, 34390 Capa, Istanbul, Turkey. e-mail: vsar{at}istanbul.edu.tr
© 2009 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND: Conversion symptoms have historically be seen to be related to dissociative disorders and early trauma. OBJECTIVE: This study sought to determine the prevalence of conversion symptoms among women in the general Turkish population. METHOD: Participants (N=628) were administered The Dissociative Disorders Interview Schedule, the Borderline Personality Disorder section of the Structured Clinical Interview for DSM–III-R Personality Disorders, and the PTSD Module of the Structured Clinical Interview for DSM–III-R; 48.7% of participants had a lifetime history of a conversion symptom. They reported various types of childhood abuse and neglect more frequently than nonconversion subjects. RESULTS: Lifetime diagnosis of major depression, dissociative disorder, and childhood physical abuse predicted a conversion symptom. Effects of childhood neglect and emotional and sexual abuse among subjects with conversion symptoms were mediated by comorbid lifetime diagnosis of major depression and dissociative disorders. CONCLUSION: The authors suggest revisions to the DSM–V regarding conversion and somatization disorders.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Conversion symptoms are historically related to the concept of hysteria. Toward the end of the 19th century, Pierre Janet conceptualized hysteria as a dissociative disorder and described medically unexplained somatic symptoms as aspects of this condition in his traumatized patients.1 Early in his career, Janet’s contemporary, Sigmund Freud, also considered hysteria a trauma-based disorder.2 However, Freud later conceptualized the somatic symptoms of hysteria as the result of repression (a defense mechanism) and referred to them as conversion symptoms. In DSM–II,3 the conversion and dissociative types of hysterical neurosis were classified as variants of a single disorder. In DSM–III4 and its subsequent versions, dissociative disorders were considered a separate group, whereas conversion disorder was classified among the somatoform disorders. Remaining close to its historical roots, the current version of the International Classification of Diseases, the ICD–105 classifies all manifestations of hysterical neurosis under the joint rubric "dissociative (conversion) disorders." This is also in accordance with the findings of modern studies that have adduced evidence for resurrecting the relationship between medically unexplained somatic symptoms and dissociative disorders;6,7 30.5% to 47.4% of patients with a conversion disorder have a concurrent DSM–IV dissociative disorder.8,9 Thus, there is a recent interest in once again reclassifying conversion disorder with the dissociative disorders section in the forthcoming DSM–V.10,11

Both somatic and psychological dissociation are correlated with reported childhood trauma.12 High sexual abuse rates have also been found in pseudoseizures13 and somatization disorder,14 and conversion-disorder patients in general.7 Sexual abuse and dissociation are independently associated with several indicators of mental health disturbance, including risk-taking behavior, such as suicidality, self-mutilation, and sexual aggression.15–17 In his lifelong career aimed at establishing a scientific medical psychology based both on biological and psychological factors, Ernst Kretschmer18,19 underscored the biological aspects of hysteria and noted the similarity between types of human and animal somatic reactions. He mentioned the "movement storm" (Bewegungssturm), and "playing-dead reflex" (Totstellreflex), which are seen in animals when threatened with death. He interpreted the symptoms of hysteria as phenomena that any person could develop under certain circumstances. Reintroducing a broader concept covering both the somatic and psychological aspects of hysteria, Braun20 devised the "BASK" model of dissociation and pointed out the disconnection between behavior (B), affect (A), sensation (S), and knowledge (K) that results from dissociation. Nijenhuis et al.21 reawakened interest in and empirically investigated the relationship between animal defensive reactions and dissociative somatic phenomena, pointing out the similarities among freezing, the concomitant development of analgesia and anesthesia, and acute pain in threatened animals and severely traumatized humans.

Representing a subtype among medically unexplained physical symptoms, conversion symptoms have become a focus of interest not only for psychiatrists, but also for internists and neurologists,22 occupying an important place in differential diagnostic procedures, consultation–liaison psychiatry, and in medical-surgical settings. To compensate for the relative lack of large-scale epidemiological studies on the subject, this study sought to document the lifetime prevalence of conversion symptoms among women in the general population. We also documented psychiatric comorbidity and childhood-trauma histories of participants with and without conversion symptoms. In order to investigate differences between a conversion disorder (a solitary conversion symptom or a limited number of conversion symptoms without fitting the criteria of a somatization disorder) and conversion symptoms in the context of a somatization disorder, a comparison between participants with and without a concomitant somatization disorder was also carried out. In the present article, we use the terms conversion and somatization disorders in a descriptive way rather than referring to a certain mechanism.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
Sampling
This study was conducted in Sivas, a city with a population of 221,500 according to the census data of 1990. The rural areas of the province, which include 546,000 people, were not included in the study. Approximately 120,000 people in the city were between 18 and 65 years of age; approximately 40% of the population are under age 18; 4% are over 65. Our target population was 60,000 women.

We used a two-stage stratified random sampling procedure. A sample set of households representative for Sivas had been previously defined by a team of sociologists.30 There were 34,831 households in 600 neighborhoods of the city. A sample size of 500 households was chosen. The households in each neighborhood were selected randomly. A random sample of 100 alternative addresses was used to replace those households where nobody was home when visited by the research team.

None of the women invited to participate in the study refused; 49 households were replaced because no one was home on either visit; 19 subjects could not be contacted because they were away from home during both visits, and they were replaced. Households were visited without prior notification. We determined the number of female residents between age 18 and 65 years in each selected household and tried to reach all of them in a maximum of two visits on the same day. Because the vast majority of the target population were housewives, it was relatively easy to contact female participants at home throughout the day. No reimbursement was paid to any participant. Written informed consent to participate in the study was obtained from each respondent.

Participants
The sample consisted of 628 women. The mean age for the entire sample was 34.8 years (standard deviation [SD]: 11.5; median: 33.0). As compared with the 1990 census data, the age range of 25–54 was slightly overrepresented in the study sample ({chi}2[3]=15.28; p<0.01). This difference may be due to a demographic change in the city that has occurred since 1990. Sivas is located in a less-industrialized part of Turkey, with low education, high unemployment, and traditional attitudes. Nearly 22% of the respondents (N=137) were illiterate; 47.1% (N=296) were primary-school graduates, 24.2% (N=152) had secondary or high school education; and 5.3% (N=33) were university graduates. Most participants (78.3%; N=492) were married; 13.1% (N=82) were single; and 8.6% (N=54) were divorced or widowed. Nearly 89% of the participants (N=556) were housewives; 7.5% (N=47) were employed; 3.0% (N=19) were students; and 1.0% (N=6) were retired. One hundred and five participants (16.8%) had been treated by a physician for a psychiatric disorder at some time.

Interviewing
The study was conducted during a 4-month period (June 1 to September 30, 1997). One male psychiatrist administered the posttraumatic stress disorder (PTSD) module of the Structured Clinical Interview for DSM–III-R (SCID) and the Borderline Personality Disorder (BPD) section of the SCID–II. A female psychiatrist administered the Dissociative Disorders Interview Schedule (DDIS) to all probands. Both evaluations were conducted privately during home visits. The interviewers had extensive experience in administering the assessment instruments; they had previously participated in various epidemiological studies in Sivas.

Instruments
Dissociative Disorders Interview Schedule (DDIS) The DDIS is a structured interview consisting of 132 items.23 It makes DSM–IV diagnoses of somatization disorder, major depressive episode, borderline personality disorder, and all of the dissociative disorders. The DDIS also inquires about childhood physical and sexual abuse. Two items about childhood emotional abuse and neglect, which are not included in the English-language DDIS, were added to the Turkish version. The DDIS has an overall interrater reliability ({kappa}) of 0.68; it has a sensitivity of 90% and a specificity of 100% for the diagnosis of dissociative identity disorder.23 Information about the validity and reliability of the Turkish Version of the DDIS has been reported elsewhere.24 The DDIS was used successfully in a previous epidemiological study in Turkey in combination with blinded clinical interviews.25

Structured Clinical Interview for DSM–III-R (SCID) The PTSD module of the SCID26 has a sensitivity of 0.69 and specificity of 1.00 for the diagnosis of PTSD, with an overall interrater agreement of 0.76.27

The Structured Clinical Interview for DSM–III-R Personality Disorders (SCID–II) The SCID–II28 is a semistructured interview that makes diagnoses of the DSM–III-R personality disorders. The SCID–II’s section for borderline personality disorder (BPD) was administered in this study. The Turkish version29 of the BPD section of the SCID–II has a reliability ({kappa}) of 0.95.

Sociodemographic data and a list of Criterion-A traumatic life events were obtained from each participant.30


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
The lifetime prevalence of conversion symptoms among women in the general population of Sivas was 48.7% (N=306). Table 1 portrays the distribution of specific conversion symptoms. Dizziness and fainting or loss of consciousness were the most prevalent conversion symptoms, 22.9% and 22.1%, respectively; 3.8% of the participants reported nonepileptic seizures or convulsions. Most of the participants in the conversion group had only one conversion symptom (N=133; 43.5%); 71 participants (23.2%) had two; 48 (15.7%) had three; and 54 participants (17.6%) had four-or-more conversion symptoms. In the group, 10.5% of the participants with a conversion symptom (N=32) also had multiple somatic complaints sufficient to fit the diagnostic criteria of a DSM–IV somatization disorder, for an overall prevalence of 5.1% in the community.


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TABLE 1. Lifetime Prevalence of Conversion Symptoms Among Women in the General Population According to Somatization Disorder Status (N=628)



The conversion-symptom group had significantly higher comorbidity for lifetime and current major depression, dissociative disorders, and borderline personality disorder than the nonconversion group (Table 2). They also reported more suicide attempts and self-mutilation. These features were significantly more prominent in the subgroup with somatization disorder than in the conversion-disorder group, indicating a more severe clinical condition . The subgroup with somatization disorder reported dizziness, vomiting, blurred vision, difficulty swallowing, and pseudoseizures more frequently than the conversion-disorder group (Table 1). Curiously, none of the somatization-disorder subjects had depersonalization disorder, whereas all subjects with a dissociative identity disorder had a conversion symptom (Table 2).


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TABLE 2. Psychiatric Comorbidity and Mental Health History Among Women in the General Population by Somatization- and Conversion-Disorder Status



Although there was no difference between the groups in their exposure to PTSD Criterion-A traumatic events and PTSD (Table 2), conversion-symptom subjects reported a higher frequency of all types of childhood abuse and neglect (Table 3). To prove a potential complex relationship between childhood trauma, comorbid psychiatric disorders, and conversion symptoms, four separate regression analyses were conducted (Table 4). Among four types of childhood trauma, only physical abuse predicted conversion symptoms. Whereas lifetime diagnosis of major depression and dissociative disorder predicted conversion symptoms, both disorders were also predicted by various types of childhood trauma: Neglect and emotional abuse predicted major depression, and neglect and sexual abuse predicted dissociative disorder.


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TABLE 3. Childhood Trauma History of Women by Conversion- and Somatization-Disorder Status




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TABLE 4. Predictors of Conversion Symptoms and Comorbid Psychiatric Disorders With Logistic-Regression Analysis




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The lifetime prevalence of conversion symptoms among women in the general population of Sivas was extremely high (48.7%). Although comparable large-scale studies concerning the prevalence of conversion symptoms in a general population are rather scarce, this finding is not at odds with rates obtained by previous studies in Turkey. Thus, among outpatients who were admitted to a primary healthcare institution in a semirural area near Ankara, Turkey, the prevalence of conversion symptoms in the preceding month was 27.2%.31 The lifetime rate of conversion symptoms for this sample was 48.2%; that is, lifetime prevalence rates in nonclinical and clinical settings were very similar. Notwithstanding possible differences in prevalence rates between various countries because of possible cultural influences, further studies also suggest that conversion symptoms are frequently seen in general-medical settings, and in neurological units, particularly. Pseudoseizure, one of the most frequent types of conversion disorder in Turkey,32 has been a focus.33 Thus, although some authors claim that hysteria is no longer a psychiatric diagnostic category and is only a subject for medical historians,34 hysteria, itself, can hardly be considered "extinct."

Because of its transient nature and comorbidity issues, determining the place of a conversion symptom among related diagnostic categories is, however, rather problematic. Shared symptoms and definitional issues, (e.g., conversion disorder versus conversion symptom in the context of somatization disorder or conversion disorder versus conversion symptom in the context of an anxiety or mood disorder) and change of clinical condition over time (e.g., major depression after the resolution of conversion disorder) make the boundaries of conversion disorder hard to define. Nevertheless, patients with conversion disorder have overall psychiatric symptom scores close to those of general-psychiatric patients,35 suggesting high psychiatric comorbidity. In a primary healthcare center in Turkey, conversion symptoms were more frequently observed among subjects who had an ICD–10 diagnosis of depression, generalized anxiety disorder, and neurasthenia.31 In the present study, compared with non-conversion subjects, those with a conversion symptom had a higher frequency of major depressive disorder, somatization disorder, dissociative disorder, borderline personality disorder, suicide attempts, and self-mutilation (Table 2). These findings are in accord with studies that have documented wide overlaps among these categories.36–38

In an effort to develop a strictly medical model of psychiatric disorders, the so-called St. Louis, MO, school, a research group from Washington University, adopted the earlier work of French physician Pierre Briquet, and redefined hysteria (Briquet’s syndrome) as a chronic disorder with multiple somatic complaints, today known as somatization disorder.39 Researchers following this tradition have also investigated possible genetic links among somatization disorder, antisocial personality disorder, and alcoholism.40 However, refuting this approach, only 10.5% of the participants in the present study who had a conversion symptom had a DSM–IV somatization disorder. Thus, for a majority of subjects, conversion symptoms represented either conversion disorder per se or were comorbid with a psychiatric disorder other than somatization disorder.

In keeping with the dissociative and conversion types of ICD–9 (and DSM–II hysteria), ICD–10 maintains the grouping under the compromise heading "dissociative (conversion) disorders."5 However, in the present study, only 26.5% of the subjects with a conversion disorder had a concurrent DSM–IV dissociative disorder. In two previous studies conducted on patients gathered from clinical settings, 30.1%–47.4% of patients with a conversion disorder had a concurrent DSM–IV dissociative disorder.8,9 Thus, despite significant overlap between the two categories, conversion symptoms do not solely occur in the context of a DSM–IV dissociative disorder, either. However, this does not necessarily suggest that conversion symptoms are not dissociative in nature.

An alternative explanation might be the differentiation of somatoform from "psychoform" dissociation. Namely, Nijenhuis et al. 41 conceptualize conversion phenomena as a kind of somatoform dissociation, contrasting with psychoform dissociation. In fact, somatoform dissociation differentiates dissociative-disorder patients from other diagnostic groups,42 suggesting a significant link between somatoform and psychoform dissociation. Somatoform and psychoform dissociation are correlated both with each other and also with reports of childhood trauma.43 This notion is in accordance with the BASK model of dissociation, which points out not only the disconnection between behavior, affect, and knowledge, but also between them and sensation.20

Patients with dissociative disorders frequently report childhood abuse and neglect.44 However, the relationship between conversion symptoms and childhood trauma history has yielded conflicted results in clinical groups. A Dutch study reported elevated rates of childhood trauma in conversion disorder.45 Emotional abuse was a significant predictor of dissociation scores among Turkish patients with conversion disorder.9 Another Dutch study on patients with conversion disorder or chronic pelvic pain did not demonstrate a relationship between childhood trauma and dissociation in general; however, somatoform dissociation was related to physical abuse in childhood. After controlling for the overall level of psychopathology, the authors recommended that clinicians should be more alert to recent potentially traumatizing experiences or comorbid psychiatric disorders.46 In a third Dutch study of subjects with frequent childhood trauma histories and elevated dissociation scores, the authors concluded that the role of childhood trauma and dissociation in conversion disorder is not clear after controlling for overall psychopathology.47 They emphasize that psychological (psychoform) dissociation scales might not be able to assess dissociation in conversion disorder, but a measure specific for somatoform dissociation might better demonstrate this relationship.

In the present study, there was no difference in the frequency of DSM–IV Criterion A-type traumatic experiences or PTSD between the two groups (Table 3). There was, however, significant trauma not captured by the PTSD criteria. The conversion-symptom group reported childhood neglect and each type of childhood abuse more frequently than did non-conversion subjects, although only physical abuse predicted conversion symptoms in regression analysis. Thus, although these subjects are usually people with experiences of childhood adversity, the relationship between various types of childhood trauma and conversion symptom is not a direct one, except in the case of physical abuse; that is, the effect of other types of childhood trauma may be mediated through major depression and dissociative disorders (Table 4). In the present regression analysis, both disorders were predictors of conversion symptoms, and they were also predicted by neglect and childhood sexual or emotional abuse. A previous study documented that conversion patients with a comorbid dissociative disorder have not only a higher number of comorbid psychiatric disorders, in general (including major depression), but they may also report more childhood trauma, suicide attempts, and self-mutilation.9

We conclude that conversion symptoms may be part of a larger complex of psychopathology, with the temporary predominance of somatization disorder, major depression, dissociative disorder, or any combination of them. However, conversion symptoms may also occur as solitary phenomena or as a combination of various conversion symptoms constituting a conversion disorder.48 Somatization disorder and conversion disorder seem to represent two poles on a severity spectrum of somatoform phenomena. The conversion group reported a higher frequency of childhood trauma than non-conversion subjects, and the rates of childhood trauma in the present study were highest in the somatization-disorder group. Previous studies have also frequently reported childhood trauma, not only in dissociative disorders but also in somatization disorder.49 Curiously, there was no difference in dissociation scores between subjects with somatization disorder and those with conversion disorder.50 Episodes of major depression and suicide attempts16,44 seem to be complications throughout the course of this process, which may also be a result of lack of appropriate psychiatric or psychotherapeutic treatment.

Proposing a new category of "complex" PTSD, Van der Kolk and colleagues51 emphasized that PTSD, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to trauma; that is, they often occur together, but traumatized individuals may suffer from various combinations of symptoms over time.

However, recent studies demonstrate that PTSD and dissociative disorders differ in many aspects.52 Thus, rather than being considered a component of PTSD, somatization disorder may be moved to dissociative disorders in DSM–V, alongside conversion disorder. In fact, there are recent proposals about abolishing the somatoform-disorders section of the DSM and moving its subcategories to their related sections.53 Conversion symptoms represent state-dissociation,54 rather than trait-dissociation, which is more specific for "psychoform" dissociative disorders as defined in the DSM. In contrast to the ICD–10, the dissociative-disorders section of the DSM–IV covers mainly chronic conditions and keeps somatoform dissociation separate from them. Thus, a renewed definition of dissociation and new criteria of dissociative disorders in the DSM–V should include somatoform dissociative phenomena, as well. Better representation of acute transient (somatoform as well as psychoform) dissociative phenomena would also make the dissociative-disorders section more complete and would make it closer to that of the ICD–10. There are welcome proposals to reclassify conversion disorder and somatization disorder55 as well as conversion seizures10,11 as dissociative disorders, as well as proposals to improve their diagnostic criteria.

A number of cultural characteristics emerged in the present study. The first is that the prevalence of substance use was very low. Although substance use is rising in Turkey, it is less prevalent among women and in regions like Sivas, where traditional attitudes prevail. Social control by the community and by families, made possible by close interpersonal relationships, seems to play a role in protecting this generation against substance use. Because substance use may chemically initiate dissociative experiences, absence of substance use in the present study increases the reliability of the diagnoses. Also, as was the case in a previous epidemiological study of the general population in Sivas,34 no one refused to participate in the study. Apparently, Turkish participants consider nonprofit, unfunded scientific work as a humanitarian activity. The extensive previous experience and high-level training of the interviewers may also have contributed to this cooperative attitude. The main limitation of the present study is that the diagnosis was made solely on the basis of a structured psychiatric interview. In fact, the diagnosis of conversion disorder can be made only after the elimination of medical causes. However, this is not feasible in a large-scale epidemiological study, especially for symptoms that are usually so transient.

It is noteworthy that in the present study only 24.5% of the conversion group had previous psychiatric treatment (Table 3). Thus, the majority of these cases in the community remain unrecognized and untreated except for those who visit emergency psychiatry wards when in a crisis situation.56 Given the subjects’ reports of substantial childhood adversity and psychiatric comorbidity, we conclude that conversion disorder warrants more interest among clinicians.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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