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Conversion Symptoms in Adolescents
Symposium on Adolescent Medicine
Conversion Symptoms in Adolescents
Stanford B. Friedman, MD.*
Somatic symptoms resulting from psychological and emotional factors may be caused by various psychic and physiologic processes. 7 This paper, however, will be limited to a discussion of conversion symptoms as they relate to the medical care of adolescents. This emphasis would appear warranted by the significant incidence of conversion symptoms in adolescents, often seen repeatedly by physicians for what appears to be organic disease, and the frequency with which such symptoms are misdiagnosed and patients poorly managed. Further, physicians commonly feel frustrated in their attempt to help the child or adolescent who by physical examination and laboratory findings is healthy, yet presents with somatic complaints. Jimmy was such a patient. At 12 years of age, he had an 8 month history of vaguely defined nausea, abdominal pain, and headaches .. He had been seen during this period by two pediatricians, a pediatric allergist, a pediatric neurologist, a surgeon, and an ear, nose, and throat specialist. He had received multiple drugs including antihistamines, anticonvulsants, antacids, and migraine medication, and had been hospitalized twice for diagnostic evaluations. Jimmy insisted that his symptoms never entirely disappeared, but that he was "learning to live" with the everpresent feeling of nausea, "achey" abdominal pain, and frequent headaches. As a last resort, his parents finally agreed to investigate the possible psychological etiology of his symptoms, which were then diagnosed as conversion reactions. However, Jimmy's parents persisted in believing his symptoms were due to a "physical disease," and rejected the suggestion that Jimmy receive psychological help.
This brief vignette illustrates the usual search for a physical, or "organic," cause of the symptoms and the numerous referrals to medical subspecialists. When a psychological etiology was eventually considered, both the boy's pediatrician and his parents were committed to finding a "real," physical cause for his symptoms. Jimmy and his parents had "learned to live" with the problem, and psychiatric treatment now represented a threat of disruption of a psychological equilibrium shared by all family members. 'Professor of Psychiatry and Human Development, and Professor of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland. Supported in part by U.S. Public Health Grant No. K3-MH-18, 542, from the National Institute of Mental Health.
Pediatric Clinics of North America- Vol. 20, No.4, November 1973
873
874
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FRIEDMAN
DESCRIPTION AND INCIDENCE OF CONVERSION SYMPTOMS The process of conversion has been defined by Enge1 4 as "a psychic mechanism whereby an idea, fantasy, or wish is expressed in bodily rather than verbal terms and is experienced by the patient as a physical rather than a mental symptom." This unconscious process can occur when direct expression, or acknowledgment, of the wish is psychologically threatening or unacceptable to the individual, and the conversion symptom may be seen as a compromise to avoid the anxiety that would result from acknowledgment of the unacceptable. The wish is unconscious, and thus the patient does not relate his psychic conflict to his somatic symptoms. Hollender9 discusses such symptoms (hysterical language) as a code concealed from the sender as well as from the receiver. Conversion symptoms are protean and may mimic many diseases. Enge1 4 and Malmquist ll have listed those symptoms that may result from the process of conversion, and any bodily function that may be perceived or sensed by the individual can be involved. Paralysis or weakness of the limbs, blindness, anesthesia, pain, hyperventilation, and dizziness are only representative of symptoms that may be involved in the conversion process. Actual bodily changes may be secondary to a conversion symptom, and have been described as a complication of the symptom and not as part of the conversion reaction per se. 3 Thus, muscle atropy may be seen in patients with long-standing paralysis and respiratory alkalosis may result from episodes of hyperventilation. Such secondary changes should be differentiated from psychophysiologically mediated lesions, such as peptic ulcers. Based on our clinical experience in the Adolescent Clinic at the University of Rochester, abdominal pain, headaches, dizziness, and hyperventilation would appear to be particularly common conversion symptoms among teenagers. The incidence of conversion symptoms among adolescents is, however, unknown. In reviewing the literature, Rock 15 finds little agreement on the frequency of conversion symptoms in children and adolescents and concludes "whether it [conversion reaction] is common, frequent, or rare ... is still unanswered." Proctor 14 reports a 13 per cent incidence figure for 191 consecutively diagnosed cases in a child psychiatry unit. In adults seen in medical centers, Ziegler 16 states that it is generally estimated that 5 to 20 per cent of patients seen for diagnostic purposes have conversion symptoms. Apleyl reported an incidence of recurrent abdominal pain in children of 9.5 per cent in boys and 12.3 per cent in girls. In 100 cases of abdominal pain extensively investigated, in only 8 instances did he find an "organic cause." Oster12 found a similar overall incidence (14.4 per cent) of abdominal pain in another population of children, with maximal incidence at 9 years of age falling to approximately 5 per cent at 16 to 17 years of age. He further suggested, based on his findings, "that the child's environment with frequent manifestations of pain in the parents may be a precipitating factor for the children's painful experiences." This author believes that the somatic complaints in the majority of children and ado-
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lescents reported in series such as these are, in reality, conversion symptoms. Malingering, on the other hand, is rare in adolescents, except in institutional settings.
CRITERIA FOR THE DIAGNOSIS As previously mentioned, conversion symptoms may be seen as a form of communication in which the patient is expressing an unconscious wish or thought. Further, the nature of the symptom is not a chance or random phenomenon, but has been found to have specific, symbolic meaning to the patient. Thus, a teenager, finding his wish to masturbate conflictual and unacceptable, may develop a paralysis of his hand or arm. Of interest is that the conversion symptom, in this case a paralysis, often prevents the very expression of the wish. The symptoms, as described by Engel,4 "derive from stored mental representation (memories) of bodily activities or functioning which are utilized to express symbolically unconscious wishes or impulses as a means of coping with a psychological conflict." However, in the setting of delivering general medical care to adolescents, the nature of the conflict and the symbolic meaning of the symptom often are not apparent to the physician. A presumptive diagnosis, nevertheless, can be made in the majority of cases by eliciting a pattern of behavior common to adolescents with conversion symptoms. The diagnosis should be supported by positive criteria, rather than the mere absence of physical and laboratory findings. A potential danger in the latter approach is illustrated in the following case history.
Jill was a 17 year old girl who over a period of 6 months complained of intense pain of one knee. Repeated physical examinations and an x-ray of the leg did not reveal any lesion, and her parents were told by her physician that the problem was "psychogenic." She was then openly accused of "faking" by family and friends, and eventually referred to the Behavioral Pediatric Group. The girl had a history of minor emotional problems, related to parental overprotection and overindulgence. She also displayed paranoid thinking, and on several occasions described her brother or mother trying to poison her. However, it was not possible to elicit any convincing positive criteria for the diagnosis of a conversion symptom. With this lack of evidence, she was admitted to the pediatric ward for further study, and after several days the diagnosis of a malignant tumor with bone destruction was made. Conversion symptoms are more commonly seen in individuals described as possessing a "hysterical personality," a term often ill-defined and ambiguous. Chodoff and Lyons2 have attempted to clarify usage of "hysterical" and included such personality characteristics as egocentricity, labile and excitable but shallow affectivity, dramatic and attention seeking behavior, sexual provocativeness, and dependently demanding in interpersonal situations. Gestures, manner of dress, and other forms of nonverbal communication are commonly used, and often are seen as sexually seductive. However, the ability to form truly intimate relationships or achieve adequate sexual adjustment is lacking. Individuals with hys-
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terical personality traits are described as "suggestible," and conversion symptoms have occurred in adolescents as epidemics. 'o Many of these personality traits are, of course, characteristic of the adolescent stage of development, and hysterical behavior, in contrast to persistent conversion symptoms, is not in itself indicative of psychopathology. Though more frequent in individuals with the hysterical type of personality, conversion also is seen in individuals not possessing these personality traits, and in male as well as female patients. 2 ,4 The hysterical pattern of behavior may influence the very reporting of the adolescent's symptoms. Vivid, sometimes bizarre, descriptions of pain or sensations are common; for instance, one adolescent boy described the "burning of the soles of his feet by thousands of hot needles." Disabilities resulting from symptoms are frequently exaggerated, and may actually be acted out by the patient. Symptoms mentioned by the physician may be mimicked by the patient, again demonstrating the tendency to be influenced by suggestion. Although children and adolescents with conversion symptoms may appear socially sophisticated, indeed precocious for their age, they are in fact often overly dependent upon adults and overprotected by parents. 15 Family members frequently use somatic complaints and issues of health in their everyday communication. For example, family activities may be cancelled because of mother's cramps or father's headache. Any somatic complaints by the adolescent may, therefore, fit well into the family's style of focusing on bodily functions, and his own development of a similar style of communication is repeatedly reinforced. As discussed, the conversion symptom is an attempt to resolve a psychological conflict. To the degree that it succeeds, anxiety is reduced, and this is the "primary gain" achieved by the patient. Thus, the adolescent may appear little concerned about his symptom ("la belle indifference") in spite of words to the contrary,';' and the parents themselves, though involved in obtaining medical help for their child, also may not appear truly distressed. In addition to reducing anxiety, an intrapsychic process, conversion symptoms further serve to cope with a threatening environment by a process usually referred to as "secondary gain." Thus, abdominal pain in an adolescent may result in his being excused from school, or dizziness may keep him, or her, from engaging in difficult social interactions with peers. These limitations may appear on the surface to be contrary to the adolescent's own expressed desires and he may even complain of his inability to participate in activities, but they nevertheless serve unconscious needs and remove him from situations that are potentially threatening or conflictual. The secondary gain to the adolescent also may take the form of attracting attention or expressions of love from his parents that were not forthcoming when he was asymptomatic. This latter situation is particularly resistant to change, since the symptoms are continually reinforced, "'Denial by the adolescent of physical disease and related symptoms may, however, be confused with the lack of concern characteristic of conversion, and the physician should be cautious in judging an adolescent's emotional response to his symptoms.
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and often serve to meet psychological needs of the parents as well as the patient. A "vicious cycle" situation then develops, with the adolescent and his parents becoming increasingly dependent upon the existence of the conversion symptom. The presence of "secondary gain" to the patient is not, however, proof that the symptom represents conversion. All illness is to some degree associated with secondary gain to the patient, and indeed is part of a healthy adaptation to a physical disability. A bedridden adolescent, for instance, must accept a certain" degree of extra care and attention, despite his general developmental need to assume independence and selfreliance. However, in cases of conversion, secondary gains potentiate the symptom and may therefore be temporally related to the occurrence of complaints. Further, since the secondary gain usually depends upon the response of others, a conversion symptom frequently occurs only in the presence of individuals who are meaningful to the patient. Since the conversion symptom represents an attempt to resolve or avoid a conflict, such symptoms are more apt to occur at times of stress. In adolescents, changes of schools, final examinations, new social experiences, and parental conflict may represent particularly stressful events. However, the conflict or unacceptable wish is unconscious to the patient, and often difficult to elicit in the history. Jane, a 14 year old girl, was reported to have had three episodes of hyperventilation followed by "fainting" while in school. The symptom occurred twice in the hallways during change of classes, and once on the school steps while the girl was awaiting a ride from her mother. Jane denied being upset at these times. It was eventually learned from the patient that on each occasion she had just been greeted by her counsellor, a middle-aged woman, though the girl did not attach any importance to this "coincidence." The meaning of what appeared to be a casual meeting of the girl and the counsellor was revealed only when the school principal was contacted. It was then ,.learned that this counsellor had allegedly made homosexual advances toward several girls, and that these advances were never made during scheduled interviews with students, but rather when she met them informally.
The type of symptom experienced by an individual patient, that is, symptom selection in the conversion process, is dependent on the patient's memory of bodily functioning or symptoms. However, the patient is not conscious of the connection between this memory, itself unconscious, and his conversion symptoms. The model symptoms often have occurred not in the patient, but in an individual having a significant relationship to the adolescent, such as a parent, sibling, relative, or close friend. Thus, the conversion symptom may mimic the mother's monthly cramps and headaches, or the chest pain experienced by a grandparent. It is important, though, to realize it is the adolescent's perception of the complaint or symptom in the other person that determines the characteristics of the conversion symptom. Children, and even teenagers, frequently are given partial or distorted information regarding illness, often with the motive of "protecting them from the truth," and it is this information, sometimes superimposed by their fantasies, which may serve as the model for later conversion. A previous illness or symptom experienced by the adolescent himself
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may also be the model in the conversion process. In our experience, adolescents with epilepsy who later develop conversion symptoms modeled after their own earlier seizures pose some of the most difficult diagnostic problems seen in adolescent medicine. Unfortunately, these adolescents may receive increased doses and numbers of anticonvulsant drugs, sometimes resulting in toxicity, without conversion being considered as a diagnostic possibility. Being based on a "model" symptom, the conversion symptom may closely mimic physical disease. Yet, it is generally true that the medically unsophisticated patient, including most adolescents, cannot describe his symptoms so that they are fully consistent with the pertinent anatomical structures and physiological processes. To the physician, his symptoms often "do not make medical sense." Likewise, careful physical examination, particularly the neurological portion, may reveal findings that appear to violate anatomical and physiological considerations. The well known "stocking anesthesia" is but one example of this. The medical history of the adult with conversion symptoms often reveals past unexplained somatic symptoms, and this also is true of adolescents. A history of an unwarranted tonsillectomy, bouts of abdominal pain, headaches, and frequent absenteeism from school appear to be common in the adolescent with conversion symptoms. In other cases, however, the developmental tasks of adolescence' and sexual conflicts are related to the initial appearance of conversion symptoms in adolescents. This section has focused upon the type of evidence needed for the diagnosis of conversion reaction in an adolescent (Table 1). No single criTable 1. Criteria for Diagnosis of Conversion Symptoms in Adolescents Symptom has symbolic meaning. More common in individuals with hysterical personality. Characteristic style of reporting symptoms. Parents often overprotective. Frequent use of health issues and symptoms in family communication. Apparent lack of concern about symptoms. Reduces anxiety ("primary gain"). Helps adolescent cope with environment ("secondary gain"). Symptoms occur at times of stress. Model for the symptom. Frequent medical history of past unexplained symptoms. History and findings of physical examination not consistent with anatomical and physiological concepts.
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terion is conclusive, and each varies in importance in an individual patient. Nevertheless, the diagnosis of conversion, or any other psychological diagnosis, must not merely rest on the absence of physical and laboratory findings.
MANAGEMENT It is beyond the scope of this paper to discuss psychotherapeutic techniques, and only general principles of management will be considered. It is obvious that primary care physicians, not psychiatrists, see the vast majority of adolescents with conversion symptoms. How the physician conducts his initial evaluation has a marked influence on the success of future management and subsequent acceptance of psychological considerations by the patient and his faInily. From the beginning, the physician should communicate his interest in considering the possibility of either a physical or psychological basis for the adolescent's symptoms. An initial focus only upon an "organic" etiology conveys to the adolescent, and to his parents, that psychological factors are unlikely, unimportant, and improbable. Later attention to the adolescent's emotional life is then apt to be viewed as a "last resort," representing failure on the physician's part to find the expected organic cause of the symptoms. Therefore, physical and psychological evaluation of the patient should proceed concurrently, and the latter not left to when a physical cause has been "ruled out." This approach to the diagnosis makes a psychological cause of the symptoms more acceptable to the adolescent and his parents, and also often results in fewer laboratory and special diagnostic procedures and therefore less cost to the adolescent's family. Efforts initially directed toward the psychological and social functioning of the adolescent ultimately may save the physician time that otherwise would be spent in a fruitless search for physical disease. Once the symptoms are diagnosed as being due to conversion, the physician must formulate a plan of treatment. Though, as previously noted, patients with conversion symptoms are often described as "suggestible," telling an adolescent his symptom will "go away" rarely succeeds and certainly does not help resolve the underlying psychological problem. Likewise, placebo therapy, aside from ethical considerations, has no place in the treatment of conversion. Some mode of psychotherapy is indicated, and the first issue is the question of whether to refer the patient to a psychiatric facility. It is probably fair to say that most primary care physicians - be they pediatricians, internists, faInily physicians, or general practitioners - would prefer not to treat an adolescent with conversion symptoms. Such a reluctance may be based on little interest in managing psychiatric problems, lack of appropriate training in psychiatry and/or adolescent medicine, little intellectual understanding of conversion symptoms, and the econoInic problem of doing psychotherapy in a setting geared to more traditional medical care. These factors are often expressed in the statement: "I'd like to follow this patient, but do not have the time." Appropriate referral, then, becomes an important issue.
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Referral possibilities include private psychiatric care, a child psychiatry clinic (often a unit within a university hospital or community mental health center), or a community social service agency. Private psychiatric care is limited by the available number of psychiatrists interested in and qualified to treat adolescents, and such care is, of course, generallyavailable only to the most affluent families in our society. A community mental health center may be a reasonable resource, but personnel shortages and large numbers of patients may preclude the type of help needed by the adolescent (who typically must live within the "catchment area" served by the center). Social agencies vary greatly in the ability to accept adolescents with conversion symptoms, and frequently are hesitant, because of their nonmedical orientation and staffing, to assume the major responsibility for the adolescent whose complaints are "physical" in nature. In summary, though excellent referral possibilities may exist in individual instances and in some communities, it appears clear that currently most adolescents experiencing conversion symptoms are managed, albeit with great reluctance in many cases, by primary care physicians. In reviewing 10 cases in detail, Rock'S judged that 6 could have been handled by a pediatrician without psychiatric intervention. In following an adolescent with conversion symptoms, it has been our experience that the therapeutic sessions need not be frequent or lengthy. Most adolescents, with a separate session for both parents together, are seen for 30 to 45 minutes for the first few visits, at which time the diagnosis generally can be made from the history, physical examination, and indicated laboratory procedures. A careful medical" evaluation reassures the patient and parents, but there comes a point when the probability of uncovering a physical lesion approaches zero and common sense must prevail over parental wishes for additional examinations or tests. The frequency of visits may usually decrease to once or twice a month, and rarely need to exceed 30 minutes. The adolescent is encouraged to talk about issues and problems in terms other than his somatic complaiI'tts. With younger adolescents, proportionately more time is spent with the parents, interpreting the child's symptoms to them and examining their response to his complaints. Periodically, the physician should review his progress, and decide upon future management in terms of this progress. Though the doctor "just talks" to the patient, we have found most families understand the necessary cost associated with such treatment. This level of therapeutic intervention, by its very nature, frequently must have rather limited goals, and complete disappearance of symptoms frequently is not achieved. s However, the physician's role nevertheless may be critical in preventing unnecessary, continuing diagnostic studies and inappropriate medical, and sometimes surgical, treatment. Though symptoms may persist, the adolescent may more successfully cope with them and decrease his dependency upon secondary gains. Further, Proctor'3 notes that "minimal therapeutic intervention is often effective in reinstituting the main stream of the growth process." In the minority of cases when the symptoms continue to disable the adolescent significantly and limit his activities, psychiatric consultation and/or referral should be considered.
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The eventual outcome of adolescents with conversion symptoms is not known. In a report of 74 children with "psychogenic" pain, Friedman6 found that "a substantial proportion of the patients were reported as improved after several years, whether treated or not." From evidence of this sort, it would appear that children and adolescents with "psychogenic" pain, including conversion symptoms, have a relatively good prognosis, and that the symptom may be transitory, related to environmental stress, or to a developmental crisis, and amenable to therapeutic intervention. Betty was first seen in our Adolescent Clinic as a high school freshman. Multiple somatic complaints were elicited, including frequent headaches, menstrual cramps, and feelings of dizziness. The mother's main concern, however, was a recent episode in which Betty was described as having had difficulty breathing, leading to an apparent loss of consciousness, while on a school bus returning from a class excursion to see a play. During the play, one of the main characters died of a heart attack. With this and other more detailed information, the diagnosis of convers.on reaction was made and the family referred to a psychiatric facility. Though at first accepting, Betty's mother then rejected psychiatric referral and asked for a return appointment to Adolescent Clinic. It became apparent that Betty was involved in a number of difficult situations. Her mother, a nurse, had high expectations for the girl in terms of college and ultimate social status. Her father, a factory worker, had little appreciation for his wife's hopes for Betty, and such differences regarding Betty'S future reflected major discord in the marriage. Betty, being the oldest of four girls, served as her mother's companion and confidant, and their discussions frequently focused upon family and marital problems. Further, Betty's mother was preoccupied with matters of health and disease, and she and the four children were under constant treatment by a variety of physicians and chiropractors. Betty'S symptoms gained her a great deal of attention, special privileges, and sympathy. Betty had been an honor student all through elementary school, but was having serious academic problems in high school. From school records and a discussion with Betty's counsellor, it became apparent that she had been an honor student at an enormous expense. She worked many hours each night on her homework, and was aware that anything but honor grades would bring about overt disapproval from mother. With positive criteria for conversion symptoms and normal findings on physical examination, the diagnosis was discussed with Betty and her mother. Over the next 31f2 years, Betty was seen 36 times, with the typical session approximately 30 minutes in length. The physician first focused upon the difficulties at school, and made some direct suggestions to both Betty and her mother, and then discussed these suggestions with the school counsellor. In brief, her presence in accelerated and honor classes was not consistent with her average intelligence, and a more reasonable academic schedule was arranged. The physician paid decreasing attention to Betty's somatic complaints and gradu:illy she talked more about other problems she was experiencing, including questions about dating behavior, and her mother's attitudes toward sexuality. Gradually Betty gained some understanding of her symptoms. Though she still occasion:illy experienced symptoms, Betty found that "things were better" if she did not discuss them with her mother. She understood that her mother was deeply concerned about matters of health, and eventu:illy realized that this concern was inappropriate and reflected problems her mother had. Betty, now graduated from high school, has not reported any somatic complaints over the past year. In retrospect, she believes her initial breathing difficulty, which appears to have been a typical hyperventilation episode, was "probably because I re:illy didn't want to go on the bus since I had to be with so many other kids." Thus, Betty seemed to have a limited understanding of her symptoms, perceiving them as being linked to psychological factors. Betty has found ways of relating to her mother other than communication via somatic complaints. However, she has not as yet been able to separate from
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mother and carry out her stated wish to attend a community college. She can talk about the guilt she feels in leaving her mother with the care of her three younger siblings, but even with this insight, cannot make the "break." She has recently found full time employment which allows her to live at home, and only continuing follow-up will tell us whether she ultimately reaches the point where she can achieve adult independence.
SUMMARY Though the incidence is not known, conversion symptoms appear to be relatively common in adolescents. The diagnosis depends upon eliciting a pattern of behavior and symptomatology characteristic of conversion reactions, and not merely by excluding an "organic" etiology. Clinical experience suggests that the majority of cases may be appropriately managed by primary care physicians who possess an interest in the emotional problems of adolescents and a willingness to develop basic psychiatric skills.
REFERENCES 1. Apley, J.: The Child With Abdominal Pains. Oxford, England, Blackwell Scientific Publications, 1959. 2. Chodoff, P., and Lyons, H.: Hysteria, the hysterical personality and "hysterical" conversion. Amer. J. Psychiat., 114:734, 1958. 3. Engel, G. L.: A reconsideration of the role of conversion in somatic disease. Comprehensive Psychiat., 9:316, 1968. 4. Engel, G. L.: Conversion symptoms. In MacBryde, C. M., and Blacklow, R. S., eds.: Signs and Symptoms: Applied Physiology and Clinical Interpretation. Philadelphia, J. B. Lippincott Co., 1970. 5. Erikson, E. H.: Childhood and Society. New York, W. W. Norton & Co., 1950. 6. Friedman, R.: Some characteristics of children with "psychogenic" pain, observations on prognosis and management. Clin. Pediat., 11 :331, 1972. 7. Friedman, S. B., and Glasgow, L. A.: Psychologic factors and resistance to infectious disease. PEDIAT. CLIN. N. AMER., 13:315, 1966. 8. Green, M.: Recurrent abdominal pain. In Green, M., and Haggerty, R. J., eds.: Ambulatory Pediatrics. Philadelphia, W. B. Saunders Co., 1968. 9. Hollender, M. H.: Conversion hysteria-A post-Freudian reinterpretation of nineteenth century psychosocial data. Arch. Gen. Psychiat., 26:311, 1972. 10. Knight, J. A., Friedman, T. I., and Sulianti, J.: Epidemic hysteria: A field study. Amer. J. Pub. Health,55:858, 1965. . 11. Malmquist, C. P.: Hysteria in childhood. Postgrad. Med., 50:112, 1971. 12. Oster, J.: Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics, 50:429, 1972. 13. Proctor, J. T.: The treatment of hysteria in childhood. In Hammer, M., and Kaplan, A. M., eds., The Practice of Psychotherapy with Children. Homewood, Illinois, The Dorsey Press, 1967. 14. Proctor, J. T., and Schneer, H. I.: Hysteria in Childhood. Amer. J. Orthopsychiat., 28:394, 1958. 15. Rock, N. L.: Conversion reactions in childhood: A clinical study on childhood neuroses. J. Amer. Acad. Child Psychiatry, 10:65, 1971. 16. Ziegler, F. J.: Hysterical conversion reactions. Postgrad. Med., 47:174,1970. Division of Child and Adolescent Services Department of Psychiatry University of Maryland School of Medicine Baltimore, Maryland 21201
Conversion Symptoms in Adolescents
Stanford B. Friedman, MD.*
Somatic symptoms resulting from psychological and emotional factors may be caused by various psychic and physiologic processes. 7 This paper, however, will be limited to a discussion of conversion symptoms as they relate to the medical care of adolescents. This emphasis would appear warranted by the significant incidence of conversion symptoms in adolescents, often seen repeatedly by physicians for what appears to be organic disease, and the frequency with which such symptoms are misdiagnosed and patients poorly managed. Further, physicians commonly feel frustrated in their attempt to help the child or adolescent who by physical examination and laboratory findings is healthy, yet presents with somatic complaints. Jimmy was such a patient. At 12 years of age, he had an 8 month history of vaguely defined nausea, abdominal pain, and headaches .. He had been seen during this period by two pediatricians, a pediatric allergist, a pediatric neurologist, a surgeon, and an ear, nose, and throat specialist. He had received multiple drugs including antihistamines, anticonvulsants, antacids, and migraine medication, and had been hospitalized twice for diagnostic evaluations. Jimmy insisted that his symptoms never entirely disappeared, but that he was "learning to live" with the everpresent feeling of nausea, "achey" abdominal pain, and frequent headaches. As a last resort, his parents finally agreed to investigate the possible psychological etiology of his symptoms, which were then diagnosed as conversion reactions. However, Jimmy's parents persisted in believing his symptoms were due to a "physical disease," and rejected the suggestion that Jimmy receive psychological help.
This brief vignette illustrates the usual search for a physical, or "organic," cause of the symptoms and the numerous referrals to medical subspecialists. When a psychological etiology was eventually considered, both the boy's pediatrician and his parents were committed to finding a "real," physical cause for his symptoms. Jimmy and his parents had "learned to live" with the problem, and psychiatric treatment now represented a threat of disruption of a psychological equilibrium shared by all family members. 'Professor of Psychiatry and Human Development, and Professor of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland. Supported in part by U.S. Public Health Grant No. K3-MH-18, 542, from the National Institute of Mental Health.
Pediatric Clinics of North America- Vol. 20, No.4, November 1973
873
874
STANFORD
B.
FRIEDMAN
DESCRIPTION AND INCIDENCE OF CONVERSION SYMPTOMS The process of conversion has been defined by Enge1 4 as "a psychic mechanism whereby an idea, fantasy, or wish is expressed in bodily rather than verbal terms and is experienced by the patient as a physical rather than a mental symptom." This unconscious process can occur when direct expression, or acknowledgment, of the wish is psychologically threatening or unacceptable to the individual, and the conversion symptom may be seen as a compromise to avoid the anxiety that would result from acknowledgment of the unacceptable. The wish is unconscious, and thus the patient does not relate his psychic conflict to his somatic symptoms. Hollender9 discusses such symptoms (hysterical language) as a code concealed from the sender as well as from the receiver. Conversion symptoms are protean and may mimic many diseases. Enge1 4 and Malmquist ll have listed those symptoms that may result from the process of conversion, and any bodily function that may be perceived or sensed by the individual can be involved. Paralysis or weakness of the limbs, blindness, anesthesia, pain, hyperventilation, and dizziness are only representative of symptoms that may be involved in the conversion process. Actual bodily changes may be secondary to a conversion symptom, and have been described as a complication of the symptom and not as part of the conversion reaction per se. 3 Thus, muscle atropy may be seen in patients with long-standing paralysis and respiratory alkalosis may result from episodes of hyperventilation. Such secondary changes should be differentiated from psychophysiologically mediated lesions, such as peptic ulcers. Based on our clinical experience in the Adolescent Clinic at the University of Rochester, abdominal pain, headaches, dizziness, and hyperventilation would appear to be particularly common conversion symptoms among teenagers. The incidence of conversion symptoms among adolescents is, however, unknown. In reviewing the literature, Rock 15 finds little agreement on the frequency of conversion symptoms in children and adolescents and concludes "whether it [conversion reaction] is common, frequent, or rare ... is still unanswered." Proctor 14 reports a 13 per cent incidence figure for 191 consecutively diagnosed cases in a child psychiatry unit. In adults seen in medical centers, Ziegler 16 states that it is generally estimated that 5 to 20 per cent of patients seen for diagnostic purposes have conversion symptoms. Apleyl reported an incidence of recurrent abdominal pain in children of 9.5 per cent in boys and 12.3 per cent in girls. In 100 cases of abdominal pain extensively investigated, in only 8 instances did he find an "organic cause." Oster12 found a similar overall incidence (14.4 per cent) of abdominal pain in another population of children, with maximal incidence at 9 years of age falling to approximately 5 per cent at 16 to 17 years of age. He further suggested, based on his findings, "that the child's environment with frequent manifestations of pain in the parents may be a precipitating factor for the children's painful experiences." This author believes that the somatic complaints in the majority of children and ado-
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lescents reported in series such as these are, in reality, conversion symptoms. Malingering, on the other hand, is rare in adolescents, except in institutional settings.
CRITERIA FOR THE DIAGNOSIS As previously mentioned, conversion symptoms may be seen as a form of communication in which the patient is expressing an unconscious wish or thought. Further, the nature of the symptom is not a chance or random phenomenon, but has been found to have specific, symbolic meaning to the patient. Thus, a teenager, finding his wish to masturbate conflictual and unacceptable, may develop a paralysis of his hand or arm. Of interest is that the conversion symptom, in this case a paralysis, often prevents the very expression of the wish. The symptoms, as described by Engel,4 "derive from stored mental representation (memories) of bodily activities or functioning which are utilized to express symbolically unconscious wishes or impulses as a means of coping with a psychological conflict." However, in the setting of delivering general medical care to adolescents, the nature of the conflict and the symbolic meaning of the symptom often are not apparent to the physician. A presumptive diagnosis, nevertheless, can be made in the majority of cases by eliciting a pattern of behavior common to adolescents with conversion symptoms. The diagnosis should be supported by positive criteria, rather than the mere absence of physical and laboratory findings. A potential danger in the latter approach is illustrated in the following case history.
Jill was a 17 year old girl who over a period of 6 months complained of intense pain of one knee. Repeated physical examinations and an x-ray of the leg did not reveal any lesion, and her parents were told by her physician that the problem was "psychogenic." She was then openly accused of "faking" by family and friends, and eventually referred to the Behavioral Pediatric Group. The girl had a history of minor emotional problems, related to parental overprotection and overindulgence. She also displayed paranoid thinking, and on several occasions described her brother or mother trying to poison her. However, it was not possible to elicit any convincing positive criteria for the diagnosis of a conversion symptom. With this lack of evidence, she was admitted to the pediatric ward for further study, and after several days the diagnosis of a malignant tumor with bone destruction was made. Conversion symptoms are more commonly seen in individuals described as possessing a "hysterical personality," a term often ill-defined and ambiguous. Chodoff and Lyons2 have attempted to clarify usage of "hysterical" and included such personality characteristics as egocentricity, labile and excitable but shallow affectivity, dramatic and attention seeking behavior, sexual provocativeness, and dependently demanding in interpersonal situations. Gestures, manner of dress, and other forms of nonverbal communication are commonly used, and often are seen as sexually seductive. However, the ability to form truly intimate relationships or achieve adequate sexual adjustment is lacking. Individuals with hys-
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terical personality traits are described as "suggestible," and conversion symptoms have occurred in adolescents as epidemics. 'o Many of these personality traits are, of course, characteristic of the adolescent stage of development, and hysterical behavior, in contrast to persistent conversion symptoms, is not in itself indicative of psychopathology. Though more frequent in individuals with the hysterical type of personality, conversion also is seen in individuals not possessing these personality traits, and in male as well as female patients. 2 ,4 The hysterical pattern of behavior may influence the very reporting of the adolescent's symptoms. Vivid, sometimes bizarre, descriptions of pain or sensations are common; for instance, one adolescent boy described the "burning of the soles of his feet by thousands of hot needles." Disabilities resulting from symptoms are frequently exaggerated, and may actually be acted out by the patient. Symptoms mentioned by the physician may be mimicked by the patient, again demonstrating the tendency to be influenced by suggestion. Although children and adolescents with conversion symptoms may appear socially sophisticated, indeed precocious for their age, they are in fact often overly dependent upon adults and overprotected by parents. 15 Family members frequently use somatic complaints and issues of health in their everyday communication. For example, family activities may be cancelled because of mother's cramps or father's headache. Any somatic complaints by the adolescent may, therefore, fit well into the family's style of focusing on bodily functions, and his own development of a similar style of communication is repeatedly reinforced. As discussed, the conversion symptom is an attempt to resolve a psychological conflict. To the degree that it succeeds, anxiety is reduced, and this is the "primary gain" achieved by the patient. Thus, the adolescent may appear little concerned about his symptom ("la belle indifference") in spite of words to the contrary,';' and the parents themselves, though involved in obtaining medical help for their child, also may not appear truly distressed. In addition to reducing anxiety, an intrapsychic process, conversion symptoms further serve to cope with a threatening environment by a process usually referred to as "secondary gain." Thus, abdominal pain in an adolescent may result in his being excused from school, or dizziness may keep him, or her, from engaging in difficult social interactions with peers. These limitations may appear on the surface to be contrary to the adolescent's own expressed desires and he may even complain of his inability to participate in activities, but they nevertheless serve unconscious needs and remove him from situations that are potentially threatening or conflictual. The secondary gain to the adolescent also may take the form of attracting attention or expressions of love from his parents that were not forthcoming when he was asymptomatic. This latter situation is particularly resistant to change, since the symptoms are continually reinforced, "'Denial by the adolescent of physical disease and related symptoms may, however, be confused with the lack of concern characteristic of conversion, and the physician should be cautious in judging an adolescent's emotional response to his symptoms.
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and often serve to meet psychological needs of the parents as well as the patient. A "vicious cycle" situation then develops, with the adolescent and his parents becoming increasingly dependent upon the existence of the conversion symptom. The presence of "secondary gain" to the patient is not, however, proof that the symptom represents conversion. All illness is to some degree associated with secondary gain to the patient, and indeed is part of a healthy adaptation to a physical disability. A bedridden adolescent, for instance, must accept a certain" degree of extra care and attention, despite his general developmental need to assume independence and selfreliance. However, in cases of conversion, secondary gains potentiate the symptom and may therefore be temporally related to the occurrence of complaints. Further, since the secondary gain usually depends upon the response of others, a conversion symptom frequently occurs only in the presence of individuals who are meaningful to the patient. Since the conversion symptom represents an attempt to resolve or avoid a conflict, such symptoms are more apt to occur at times of stress. In adolescents, changes of schools, final examinations, new social experiences, and parental conflict may represent particularly stressful events. However, the conflict or unacceptable wish is unconscious to the patient, and often difficult to elicit in the history. Jane, a 14 year old girl, was reported to have had three episodes of hyperventilation followed by "fainting" while in school. The symptom occurred twice in the hallways during change of classes, and once on the school steps while the girl was awaiting a ride from her mother. Jane denied being upset at these times. It was eventually learned from the patient that on each occasion she had just been greeted by her counsellor, a middle-aged woman, though the girl did not attach any importance to this "coincidence." The meaning of what appeared to be a casual meeting of the girl and the counsellor was revealed only when the school principal was contacted. It was then ,.learned that this counsellor had allegedly made homosexual advances toward several girls, and that these advances were never made during scheduled interviews with students, but rather when she met them informally.
The type of symptom experienced by an individual patient, that is, symptom selection in the conversion process, is dependent on the patient's memory of bodily functioning or symptoms. However, the patient is not conscious of the connection between this memory, itself unconscious, and his conversion symptoms. The model symptoms often have occurred not in the patient, but in an individual having a significant relationship to the adolescent, such as a parent, sibling, relative, or close friend. Thus, the conversion symptom may mimic the mother's monthly cramps and headaches, or the chest pain experienced by a grandparent. It is important, though, to realize it is the adolescent's perception of the complaint or symptom in the other person that determines the characteristics of the conversion symptom. Children, and even teenagers, frequently are given partial or distorted information regarding illness, often with the motive of "protecting them from the truth," and it is this information, sometimes superimposed by their fantasies, which may serve as the model for later conversion. A previous illness or symptom experienced by the adolescent himself
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may also be the model in the conversion process. In our experience, adolescents with epilepsy who later develop conversion symptoms modeled after their own earlier seizures pose some of the most difficult diagnostic problems seen in adolescent medicine. Unfortunately, these adolescents may receive increased doses and numbers of anticonvulsant drugs, sometimes resulting in toxicity, without conversion being considered as a diagnostic possibility. Being based on a "model" symptom, the conversion symptom may closely mimic physical disease. Yet, it is generally true that the medically unsophisticated patient, including most adolescents, cannot describe his symptoms so that they are fully consistent with the pertinent anatomical structures and physiological processes. To the physician, his symptoms often "do not make medical sense." Likewise, careful physical examination, particularly the neurological portion, may reveal findings that appear to violate anatomical and physiological considerations. The well known "stocking anesthesia" is but one example of this. The medical history of the adult with conversion symptoms often reveals past unexplained somatic symptoms, and this also is true of adolescents. A history of an unwarranted tonsillectomy, bouts of abdominal pain, headaches, and frequent absenteeism from school appear to be common in the adolescent with conversion symptoms. In other cases, however, the developmental tasks of adolescence' and sexual conflicts are related to the initial appearance of conversion symptoms in adolescents. This section has focused upon the type of evidence needed for the diagnosis of conversion reaction in an adolescent (Table 1). No single criTable 1. Criteria for Diagnosis of Conversion Symptoms in Adolescents Symptom has symbolic meaning. More common in individuals with hysterical personality. Characteristic style of reporting symptoms. Parents often overprotective. Frequent use of health issues and symptoms in family communication. Apparent lack of concern about symptoms. Reduces anxiety ("primary gain"). Helps adolescent cope with environment ("secondary gain"). Symptoms occur at times of stress. Model for the symptom. Frequent medical history of past unexplained symptoms. History and findings of physical examination not consistent with anatomical and physiological concepts.
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terion is conclusive, and each varies in importance in an individual patient. Nevertheless, the diagnosis of conversion, or any other psychological diagnosis, must not merely rest on the absence of physical and laboratory findings.
MANAGEMENT It is beyond the scope of this paper to discuss psychotherapeutic techniques, and only general principles of management will be considered. It is obvious that primary care physicians, not psychiatrists, see the vast majority of adolescents with conversion symptoms. How the physician conducts his initial evaluation has a marked influence on the success of future management and subsequent acceptance of psychological considerations by the patient and his faInily. From the beginning, the physician should communicate his interest in considering the possibility of either a physical or psychological basis for the adolescent's symptoms. An initial focus only upon an "organic" etiology conveys to the adolescent, and to his parents, that psychological factors are unlikely, unimportant, and improbable. Later attention to the adolescent's emotional life is then apt to be viewed as a "last resort," representing failure on the physician's part to find the expected organic cause of the symptoms. Therefore, physical and psychological evaluation of the patient should proceed concurrently, and the latter not left to when a physical cause has been "ruled out." This approach to the diagnosis makes a psychological cause of the symptoms more acceptable to the adolescent and his parents, and also often results in fewer laboratory and special diagnostic procedures and therefore less cost to the adolescent's family. Efforts initially directed toward the psychological and social functioning of the adolescent ultimately may save the physician time that otherwise would be spent in a fruitless search for physical disease. Once the symptoms are diagnosed as being due to conversion, the physician must formulate a plan of treatment. Though, as previously noted, patients with conversion symptoms are often described as "suggestible," telling an adolescent his symptom will "go away" rarely succeeds and certainly does not help resolve the underlying psychological problem. Likewise, placebo therapy, aside from ethical considerations, has no place in the treatment of conversion. Some mode of psychotherapy is indicated, and the first issue is the question of whether to refer the patient to a psychiatric facility. It is probably fair to say that most primary care physicians - be they pediatricians, internists, faInily physicians, or general practitioners - would prefer not to treat an adolescent with conversion symptoms. Such a reluctance may be based on little interest in managing psychiatric problems, lack of appropriate training in psychiatry and/or adolescent medicine, little intellectual understanding of conversion symptoms, and the econoInic problem of doing psychotherapy in a setting geared to more traditional medical care. These factors are often expressed in the statement: "I'd like to follow this patient, but do not have the time." Appropriate referral, then, becomes an important issue.
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Referral possibilities include private psychiatric care, a child psychiatry clinic (often a unit within a university hospital or community mental health center), or a community social service agency. Private psychiatric care is limited by the available number of psychiatrists interested in and qualified to treat adolescents, and such care is, of course, generallyavailable only to the most affluent families in our society. A community mental health center may be a reasonable resource, but personnel shortages and large numbers of patients may preclude the type of help needed by the adolescent (who typically must live within the "catchment area" served by the center). Social agencies vary greatly in the ability to accept adolescents with conversion symptoms, and frequently are hesitant, because of their nonmedical orientation and staffing, to assume the major responsibility for the adolescent whose complaints are "physical" in nature. In summary, though excellent referral possibilities may exist in individual instances and in some communities, it appears clear that currently most adolescents experiencing conversion symptoms are managed, albeit with great reluctance in many cases, by primary care physicians. In reviewing 10 cases in detail, Rock'S judged that 6 could have been handled by a pediatrician without psychiatric intervention. In following an adolescent with conversion symptoms, it has been our experience that the therapeutic sessions need not be frequent or lengthy. Most adolescents, with a separate session for both parents together, are seen for 30 to 45 minutes for the first few visits, at which time the diagnosis generally can be made from the history, physical examination, and indicated laboratory procedures. A careful medical" evaluation reassures the patient and parents, but there comes a point when the probability of uncovering a physical lesion approaches zero and common sense must prevail over parental wishes for additional examinations or tests. The frequency of visits may usually decrease to once or twice a month, and rarely need to exceed 30 minutes. The adolescent is encouraged to talk about issues and problems in terms other than his somatic complaiI'tts. With younger adolescents, proportionately more time is spent with the parents, interpreting the child's symptoms to them and examining their response to his complaints. Periodically, the physician should review his progress, and decide upon future management in terms of this progress. Though the doctor "just talks" to the patient, we have found most families understand the necessary cost associated with such treatment. This level of therapeutic intervention, by its very nature, frequently must have rather limited goals, and complete disappearance of symptoms frequently is not achieved. s However, the physician's role nevertheless may be critical in preventing unnecessary, continuing diagnostic studies and inappropriate medical, and sometimes surgical, treatment. Though symptoms may persist, the adolescent may more successfully cope with them and decrease his dependency upon secondary gains. Further, Proctor'3 notes that "minimal therapeutic intervention is often effective in reinstituting the main stream of the growth process." In the minority of cases when the symptoms continue to disable the adolescent significantly and limit his activities, psychiatric consultation and/or referral should be considered.
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The eventual outcome of adolescents with conversion symptoms is not known. In a report of 74 children with "psychogenic" pain, Friedman6 found that "a substantial proportion of the patients were reported as improved after several years, whether treated or not." From evidence of this sort, it would appear that children and adolescents with "psychogenic" pain, including conversion symptoms, have a relatively good prognosis, and that the symptom may be transitory, related to environmental stress, or to a developmental crisis, and amenable to therapeutic intervention. Betty was first seen in our Adolescent Clinic as a high school freshman. Multiple somatic complaints were elicited, including frequent headaches, menstrual cramps, and feelings of dizziness. The mother's main concern, however, was a recent episode in which Betty was described as having had difficulty breathing, leading to an apparent loss of consciousness, while on a school bus returning from a class excursion to see a play. During the play, one of the main characters died of a heart attack. With this and other more detailed information, the diagnosis of convers.on reaction was made and the family referred to a psychiatric facility. Though at first accepting, Betty's mother then rejected psychiatric referral and asked for a return appointment to Adolescent Clinic. It became apparent that Betty was involved in a number of difficult situations. Her mother, a nurse, had high expectations for the girl in terms of college and ultimate social status. Her father, a factory worker, had little appreciation for his wife's hopes for Betty, and such differences regarding Betty'S future reflected major discord in the marriage. Betty, being the oldest of four girls, served as her mother's companion and confidant, and their discussions frequently focused upon family and marital problems. Further, Betty's mother was preoccupied with matters of health and disease, and she and the four children were under constant treatment by a variety of physicians and chiropractors. Betty'S symptoms gained her a great deal of attention, special privileges, and sympathy. Betty had been an honor student all through elementary school, but was having serious academic problems in high school. From school records and a discussion with Betty's counsellor, it became apparent that she had been an honor student at an enormous expense. She worked many hours each night on her homework, and was aware that anything but honor grades would bring about overt disapproval from mother. With positive criteria for conversion symptoms and normal findings on physical examination, the diagnosis was discussed with Betty and her mother. Over the next 31f2 years, Betty was seen 36 times, with the typical session approximately 30 minutes in length. The physician first focused upon the difficulties at school, and made some direct suggestions to both Betty and her mother, and then discussed these suggestions with the school counsellor. In brief, her presence in accelerated and honor classes was not consistent with her average intelligence, and a more reasonable academic schedule was arranged. The physician paid decreasing attention to Betty's somatic complaints and gradu:illy she talked more about other problems she was experiencing, including questions about dating behavior, and her mother's attitudes toward sexuality. Gradually Betty gained some understanding of her symptoms. Though she still occasion:illy experienced symptoms, Betty found that "things were better" if she did not discuss them with her mother. She understood that her mother was deeply concerned about matters of health, and eventu:illy realized that this concern was inappropriate and reflected problems her mother had. Betty, now graduated from high school, has not reported any somatic complaints over the past year. In retrospect, she believes her initial breathing difficulty, which appears to have been a typical hyperventilation episode, was "probably because I re:illy didn't want to go on the bus since I had to be with so many other kids." Thus, Betty seemed to have a limited understanding of her symptoms, perceiving them as being linked to psychological factors. Betty has found ways of relating to her mother other than communication via somatic complaints. However, she has not as yet been able to separate from
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mother and carry out her stated wish to attend a community college. She can talk about the guilt she feels in leaving her mother with the care of her three younger siblings, but even with this insight, cannot make the "break." She has recently found full time employment which allows her to live at home, and only continuing follow-up will tell us whether she ultimately reaches the point where she can achieve adult independence.
SUMMARY Though the incidence is not known, conversion symptoms appear to be relatively common in adolescents. The diagnosis depends upon eliciting a pattern of behavior and symptomatology characteristic of conversion reactions, and not merely by excluding an "organic" etiology. Clinical experience suggests that the majority of cases may be appropriately managed by primary care physicians who possess an interest in the emotional problems of adolescents and a willingness to develop basic psychiatric skills.
REFERENCES 1. Apley, J.: The Child With Abdominal Pains. Oxford, England, Blackwell Scientific Publications, 1959. 2. Chodoff, P., and Lyons, H.: Hysteria, the hysterical personality and "hysterical" conversion. Amer. J. Psychiat., 114:734, 1958. 3. Engel, G. L.: A reconsideration of the role of conversion in somatic disease. Comprehensive Psychiat., 9:316, 1968. 4. Engel, G. L.: Conversion symptoms. In MacBryde, C. M., and Blacklow, R. S., eds.: Signs and Symptoms: Applied Physiology and Clinical Interpretation. Philadelphia, J. B. Lippincott Co., 1970. 5. Erikson, E. H.: Childhood and Society. New York, W. W. Norton & Co., 1950. 6. Friedman, R.: Some characteristics of children with "psychogenic" pain, observations on prognosis and management. Clin. Pediat., 11 :331, 1972. 7. Friedman, S. B., and Glasgow, L. A.: Psychologic factors and resistance to infectious disease. PEDIAT. CLIN. N. AMER., 13:315, 1966. 8. Green, M.: Recurrent abdominal pain. In Green, M., and Haggerty, R. J., eds.: Ambulatory Pediatrics. Philadelphia, W. B. Saunders Co., 1968. 9. Hollender, M. H.: Conversion hysteria-A post-Freudian reinterpretation of nineteenth century psychosocial data. Arch. Gen. Psychiat., 26:311, 1972. 10. Knight, J. A., Friedman, T. I., and Sulianti, J.: Epidemic hysteria: A field study. Amer. J. Pub. Health,55:858, 1965. . 11. Malmquist, C. P.: Hysteria in childhood. Postgrad. Med., 50:112, 1971. 12. Oster, J.: Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics, 50:429, 1972. 13. Proctor, J. T.: The treatment of hysteria in childhood. In Hammer, M., and Kaplan, A. M., eds., The Practice of Psychotherapy with Children. Homewood, Illinois, The Dorsey Press, 1967. 14. Proctor, J. T., and Schneer, H. I.: Hysteria in Childhood. Amer. J. Orthopsychiat., 28:394, 1958. 15. Rock, N. L.: Conversion reactions in childhood: A clinical study on childhood neuroses. J. Amer. Acad. Child Psychiatry, 10:65, 1971. 16. Ziegler, F. J.: Hysterical conversion reactions. Postgrad. Med., 47:174,1970. Division of Child and Adolescent Services Department of Psychiatry University of Maryland School of Medicine Baltimore, Maryland 21201