Dissociative experiences and psychopathology in conversion disorders

Journal of Psychosomatic Research, Vol. 46, No. 3, pp. 291–294, 1999 Copyright  1999 Elsevier Science Inc. All rights reserved. 0022-3999/99 $–see front matter

S0022-3999(98)00112-3

DISSOCIATIVE EXPERIENCES AND PSYCHOPATHOLOGY IN CONVERSION DISORDERS CARSTEN SPITZER,* BABETTE SPELSBERG,† HANS-JOERGEN GRABE,* BERNHARD MUNDT‡ and HARALD J. FREYBERGER* (Received 28 September 1998; accepted 15 October 1998) Abstract—The concepts of dissociation and conversion are historically linked with the first psychodynamic ideas on hysteria. However, the abolition of “hysterical neurosis” from current nosology has led to independent developments of these theoretical models. Recent studies found a high degree of somatization in dissociative disorders. However, little is known about dissociation in conversion disorders. We assessed 72 patients with conversion disorders for their dissociative and general psychopathology using the German version of the Dissociative Experience Scale (DES) and the Symptom Check List (SCL90-R). They were compared with a control group of 96 psychiatric patients suffering from various neurotic disorders, who were matched for gender and age. Dissociative symptoms were significantly more frequent in conversion disorder patients than in controls. There were no differences in the SCL-90-R scores between the two groups. Our findings support the theory of similar psychological processes underlying conversion and dissociative disorders despite their descriptive differences.  1999 Elsevier Science Inc. Keywords:

Dissociation; Conversion; Hysteria; Trauma.

INTRODUCTION

The concepts of both conversion and dissociation are historically and conceptually linked to the first psychodynamic ideas on hysteria of Janet and Freud dating back to the late 19th century [1]. Current nosology, favoring a phenomenological approach, has abandoned the classical “hysterical neurosis,” which has led to a separation of these theoretical models. This development is reflected in the DSM-IV [2], which subsumes the conversion disorders under the category of the somatoform disorders, whereas the dissociative disorders are classified separately in an independent category. Their essential feature is defined by the DSM-IV [2] as a “disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment” (p. 477). Recent studies have reported a high degree of conversion and somatoform sympDepartments of * Psychiatry and Psychotherapy and † Neurology, Ernst-Moritz-Arndt-University, Greifswald, Germany. ‡ Department of Neurology, General Hospital, Stralsund, Germany. Address correspondence to: Dr. Carsten Spitzer, Department of Psychiatry and Psychotherapy, ErnstMoritz-Arndt University, Rostocker Chaussee 70, D-18437 Stralsund, Germany. Phone: 0049-(0)3831452100; Fax: 0049-(0)3834-452105; E-mail: [email protected]

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toms and disorders in dissociative disorder patients [3–7]. In contrast, little is known about dissociation in conversion disorders. There are few studies on dissociative symptoms in patients with pseudoseizures that report dissociative psychopathology in these patients [8–11]. However, there are no published data on dissociation in conversion disorders. Assuming that conversion and dissociation are based on the same psychological mechanism [12], our objective was to test the hypothesis that dissociative symptoms are more frequent in patients with conversion disorders, whereas general psychopathology is as common as in other psychiatric conditions. METHOD Seventy-two in-patients meeting DSM-IV criteria for conversion disorder were included in the present study. They were compared with a control group of 96 psychiatric in-patients matched for gender and age, who were recruited from a larger series of patients described in detail elsewhere [13]. Of the conversion disorder patients, 54 (75%) were female and 18 (25%) were male. Their mean age was 33.06 10.4 years. The patients in the control group suffered from depressive disorders (16%), phobic and anxiety disorders (24%), adjustment disorders (32%), somatoform and other neurotic disorders (16%), and personality disorders (13%). None of these patients met criteria for conversion or dissociative disorders. All participants gave informed consent and completed the following questionnaires within the first 5 days after admission. The Dissociative Experiences Scale (DES) is a 28-item, self-administered questionnaire with good reliability and validity, which is based on the DSM definition of dissociation [14, 15]. Factor analyses yielded three subscales representing dissociative amnesia, absorption/imaginative involvement, and derealization/depersonalization [15]. The psychometric properties of the German adaptation are almost identical to the original version [13]. The revised version of the Symptom Check List 90 (SCL-90-R) is a 90-item, self-report clinical rating scale widely used to measure current psychopathology [16]. In addition to a global rating (Global Severity Index), it consists of nine subscales: somatization; obsessional compulsion; interpersonal sensitivity; depression; anxiety; anger–hostility; phobic anxiety; paranoid ideation; and psychoticism. The reliability and validity of the German version of the SCL-90-R is similar to the original version [17]. The data analyses were computed using the Statistical Package for the Social Sciences (SPSS PC1, version 4.0). Scores were expressed as group means and standard deviations. Differences between groups were compared using analyses of variance (ANOVA).

RESULTS

Of the 72 patients with conversion disorders, 21 (29%) presented with pseudoseizures, 15 (20.8%) suffered from psychogenic anesthesia and/or sensory loss, and 16 (22%) had movement disorders. The remaining 20 patients (28%) had a combination of at least two conversion disorders (e.g., paralysis and anesthesia). For the pseudoseizure patients, the mean DES score was 15.3610.5, for the subjects with psychogenic anesthesia 17.669.8, for those with movement disorders 15.968.6, and for the patients with a combination of conversion disorders it was 17.5611.4. These scores did not differ significantly (ANOVA: F50.22, p50.88). Also, there were no significant differences in the subscale scores. As shown in Table I, DES total and subscale scores were significantly higher in the patients with conversion disorders as compared with controls. There were no significant differences in any of the SCL-90-R subscales. DISCUSSION

This is the first empirical study of dissociative symptoms in patients with conversion disorders using the Dissociative Experience Scale [14, 15]. However, generaliz-

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Table I.—Dissociative and general psychopathology in patients with conversion disorders and the control group Conversion Disorder (n 5 72)

DES Amnesia Absorption Derealization SCL-90 Somatization Obsessive compulsion Interpersonal sensitivity Depression Anxiety Anger–hostility Phobic anxiety Paranoid ideation Psychoticism General Symptom Index

Control Group (n 5 96)

ANOVA

m

sd

m

sd

F

p

16.5 8.7 23.7 13.8

10.1 8.1 14.4 14.0

8.7 3.8 13.8 5.0

7.0 5.0 10.9 8.1

35.3 23.1 25.4 25.9

<0.001 <0.001 <0.001 <0.001

3.7 2.2 2.0 0.6 1.0 1.4 0.2 3.6 1.9 3.7

<0.055 <0.143 <0.155 <0.438 <0.310 <0.239 <0.663 <0.059 <0.173 <0.056

0.59 0.68 0.70 0.73 0.72 0.57 0.62 0.72 0.48 1.44

0.72 0.94 1.0 1.0 0.93 0.82 0.87 0.94 0.68 0.83

0.39 0.49 0.51 0.61 0.58 0.44 0.56 0.48 0.35 1.22

0.65 0.73 0.80 0.91 0.88 0.64 0.96 0.65 0.59 0.63

ability of our findings is limited because we only assessed patients’ self-reports of dissociative symptoms, and did not include an expert rating on dissociative psychopathology. Moreover, we did not study comorbidity with dissociative disorders. Furthermore, our control group comprised psychiatric–psychotherapeutic in-patients, but a control group of patients with dissociative disorders might have been preferable. Finally, the term “dissociation” is vague and lacks a coherent conceptual basis [18] and, consequently, modern questionnaires measure only certain aspects of the complex psychological processes [19, 20]. Despite these methodological limitations, our major finding that dissociation is very common in conversion disorder supports the close association between conversion and dissociation. So far, it was noted that pseudoseizure patients show elevated levels of dissociation [8–11]. According to our findings this also seems to apply to other forms of conversion disorders such as movement or sensory disorders. We also found that patients with conversion disorders do not differ significantly from the control patients with regard to other dimensions of psychopathology. This might correspond to a high degree of comorbidity with other psychiatric disorders, as reported previously [21, 22]. The comorbidity pattern of dissociative disorders (reviewed by Cardena and Spiegel [23]) is very similar to that of conversion disorders, supporting the theory of similar psychological processes underlying the two disorders despite their descriptive differences [12]. From a phenomenological point of view, it might therefore be reasonable to consider a reclassification of the conversion disorders with the dissociative disorders [1, 9, 12, 13]. This has been accomplished in the ICD-10 [24], and there seems to be enough evidence to justify a parallel development in the DSM, thus increasing the compatibility of the two systems. Considering the recent evidence about the role of dissociative processes following trauma, in particular childhood sexual abuse (reviewed by Bremner and Marmar

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[25]), our findings raise questions about the etiology of conversion disorders [26]. We are in need of further studies to elucidate the association between trauma, conversion, and dissociation. REFERENCES 1. Kihlstrom JF. One hundred years of hysteria. In: Lynn SJ, Rhue RW, eds. Dissociation: theoretical, clinical, and research perspectives. New York: Guilford Press 1994:365–394. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: APA 1994. 3. Saxe GN, Chinman G, Berkowitz R, Hall K, Lieberg G, Schwartz J, van der Kolk B. Somatization in patients with dissociative disorders. Am J Psychiatry 1994;151:1329–1334. 4. Ross CA, Miller SD, Reagor P, Bjornson L, Fraser GA, Anderson G. Structured interview data on 102 cases of multiple personality disorder from four centers. Am J Psychiatry 1990;147:596–601. 5. Coons PM, Bowman ES, Milstein V. Multiple personality disorder. A clinical investigation of 50 cases. J Nerv Ment Dis 1988;176:519–527. 6. Walker EA, Katon WJ, Neraas K, Jemelka RP, Massoth D. Dissociation in women with chronic pelvic pain. Am J Psychiatry 1992;149:534–537. 7. Pribor EF, Yutzy SH, Dean JT, Wetzel RD. Briquet’s syndrome, dissociation, and abuse. Am J Psychiatry 1993;150:1507–1511. 8. Bowman ES. Etiology and clinical course of pseudoseizures. Psychosomatics 1993;34:333–342. 9. Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizures subjects. Am J Psychiatry 1996;153:57–63. 10. Harden CL. Pseudoseizures and dissociative disorders: a common mechanism involving traumatic experiences. Seizure 1997;6:151–155. 11. Alper K, Devinsky O, Perrine K, Luciano D, Vazquez B, Pacia S, Rhee E. Dissociation in epilepsy and conversion nonepileptic seizures. Epilepsia 1997;38:991–997. 12. Nemiah JC. Dissociation, conversion, and somatization. In: Spiegel D, ed. Dissociative disorders: a clinical review. Lutherville, Maryland: Sidran Press 1993:104–116. 13. Spitzer C, Freyberger HJ, Stieglitz RD, Carlson EB, Kuhn G, Magdeburg N, Kessler C. Adaptation and psychometric properties of the German version of the Dissociative Experience Scale. J Trauma Stress (in press). 14. Bernstein EM, Putnam FW. Development, reliability and validity of a dissociation scale. J Nerv Ment Dis 1986;174:727–735. 15. Carlson EB, Putnam FW. An update on the Dissociative Experience Scale. Dissociation 1993; 6:16–27. 16. Derogatis LR. Symptom Checklist-90-R: administration, scoring, and procedures manual. Baltimore, Maryland: Clinical Psychometric Research 1983. 17. Franke H. Die Symptom-Checkliste von Derogatis. Deutsche Version. Weinheim: Beltz 1994. 18. Cardena E. The domain of dissociation. In: Lynn SJ, Rhue JW, eds. Dissociation. Clinical and theoretical perspectives. New York: Guilford Press 1994:15–31. 19. Carlson EB. Studying the interaction between physical and psychological states with the Dissociative Experiences Scale. In: Spiegel D, ed. Dissociation. Culture, mind, and body. Washington, DC: American Psychiatric Press 1994:41–58. 20. Steinberg M. Systematizing dissociation: symptomatology and diagnostic assessment. In: Spiegel D, ed. Dissociation. Culture, mind, and body. Washington, DC: American Psychiatric Press 1994:59–88. 21. Spitzer C, Freyberger HJ, Kessler C, Ko¨mpf D. Psychiatrische Komorbidita¨t dissoziativer Sto¨rungen in der Neurologie. Nervenarzt 1994;65:680–688. 22. Tomasson K, Kent D, Coryell W. Somatization and conversion disorders: comorbidity and demographics at presentation. Acta Psychiatrica Scand 1991;84:288–293. 23. Cardena E, Spiegel D. Diagnostic issues, criteria, and comorbidity of dissociative disorders. In: Michelson LK, Ray WJ, eds. Handbook of dissociation: theoretical, empirical, and clinical perspectives. New York: Plenum Press 1996:227–250. 24. World Health Organization. Chapter V(F): Mental and behavioural disorders, clinical descriptions and diagnostic guidelines. In: International classification of diseases, revision 10. Geneva: WHO 1991. 25. Bremner JD, Marmar CR, eds. Trauma, memory, and dissociation. Washington, DC: American Psychiatric Press 1998. 26. Alper K, Devinsky O, Perrine K, Vazquez B, Luciano D. Nonepileptic seizures and childhood sexual and physical abuse. Neurology 1993;43:1950–1953.