Schizophrenia, conversion disorder, stress and immigration

Year ago, when Taylor, my youngest son, was in third grade, he had a friend “Jeremy” (not his real name). Like us, Jeremy and his family had relocated from North America to Europe that year, where the father was employed in high tech. Jeremy was an only child. His mother told me that when they were in the final stages of moving, Jeremy woke up one day and said he had lost all sight in both his eyes. He was blind for about a week or two. You can imagine how terrifying that was for all concerned.

That’s what stress can do to the human mind, or, to turn it around, that’s what the powerful mind can do to the human body. When researchers note that there is a higher proportion of “schizophrenics” seen in the Jamaican immigrant population in England, this doesn’t surprise me. There are enough Jamaican immigrants to form a ready research pool. Moving continents and cultures is a shock. Schizophrenia is a stress reaction but no stranger than going blind is. You have to see it to believe it.

I came across a similar story to Jeremy’s when I was searching for the latest article on the teenage girls in Le Roy, New York who developed bodily tics and twitches. Jeremy had what by all accounts would be  “conversion disorder.” It used to be called hysteria.

What did happen to the girls in Le Roy? There is a fascinating article in the New York Times Magazine  by Susan Dominus. Dominus writes that when the environmental explanation for the phenomenon did not hold up, and the diagnosis was the stress-related conversion disorder, here’s what happened.

To many parents, the diagnosis was woefully inadequate, even insulting.“It’s a very hard pill for me to swallow — what are we, living in the 1600s?” the guardian of one of the girls said. Besides, kids are always stressed, and some of these kids may have been less stressed than most. On CNN, James DuPont, the father of an afflicted girl, said, “A lot of these kids were just, you know, having a happy, normal life.” Miller told me she did not buy the diagnosis, not one bit. “My daughter hasn’t had any trauma,” she said. “She was just happy, going along. She was as happy as can be.”

Like with schizophrenia, it is hard for many people to equate the really strange behavior with the stressors that many of us take for granted in our own lives.

According to Dominus:

A common thread emerged among the five girls I interviewed extensively: none had stable relationships with their biological fathers. And the father of a sixth girl had seen little of his high-school daughter until his concern about the tics galvanized their relationship. Another student was a foster child who switched foster homes shortly before his tics came on; yet another is in the custody of an older sibling. Another two have spotty contact with their fathers. One young woman I interviewed was close to homeless after she and her mother left her father’s trailer. They’re staying with a friend of a friend while her mother, who was laid off two times in the last year, tries to scrape together first and last month’s rent so they can get a place of their own.

Dominus also reveals that Dr. Rosario Trifiletti, who has diagnosed a mysterious and ill-defined “PANDAS-like illness” was unaware of the trauma in his patient’s lives:

When I spoke to him in late February, Trifiletti told me that the girls he was treating were showing dramatic signs of improvement. Katie’s parents said they believed that she was responding well to the antibiotics; Chelsey’s family reported that the drugs are helping her as well. But another patient of Trifiletti’s said she was still fainting.

When the subject of the girls’ personal backgrounds came up — the biopsychosocial factors that might be affecting their health — Trifiletti said he had not had the time to ask them about those kinds of things. The abuse, the troubling family circumstances — much of it came as news to him. “Jeez, I didn’t realize the extent,” Trifiletti said. “These aren’t things people want to talk about. I don’t know, maybe I’m wrong. It’s hard to distinguish between the drug and the placebo effect.”

Schizophrenia is much more common than conversion disorder. Yet, medicine stubbornly resists linking schizophrenia to trauma or stress factors. Medical science favors the biochemical imbalance theory of schizophrenia, almost exclusively. It’s quite insulting, really, to those of us who are wanting answers for schizophrenia, and more importantly, more meaningful help, that conversion disorder is taken more seriously than schizophrenia from the psycho/social point of view.

The psychological explanation, of course, hasn’t stopped some of the Le Roy parents from putting their teenage girls on drugs. The Dominus article reports that at least one girl is on eleven different medications! One can only presume it is because the parents don’t believe that stress alone can produce something so strange.

Well, stress can, and does.

Below are some readers’ comments to the Dominus article.

..Shame on you New York Times for writing such an offensive article. We are not in the dark ages. And to go so far as to blame these girls “instability” on living with single moms is disgusting. These girls don’t have conversion disorder. This is just a made up diagnosis for doctors that have egos so big they can’t say the words “I don’t Know”.

And, the following quote from simon Wessely is offensive to every person who has an illness that is not yet understood by science.

“Wessely, the epidemiologist, cited a medical-journal paper whose title had long resonated with him: “If You Have to Prove You Are Ill, You Can’t Get Better.”

Here is another quote from a recent Washington post article on chronic lyme that I think is more fitting for what is going on in Le Roy.

“Just because scientists don’t understand the cause of a disease doesn’t mean that it doesn’t exist.”

AS Minnesota
..All of the comments here that suggest that somehow their doctors were being “mean,” or were incompetent, or just not empathic enough because they conferred a psychological etiology just seems to further prove the point that for many folks, it IS in their head! Someone who honestly assumes that their doctor is mean for suggesting a psychological contribution has obvious psychological issues. Do you honestly think your doctor is intentionally trying to be mean to you? Why so defensive?? What is so threatening about a psychological diagnosis?? We experience physical symptoms as a result of psychological stress all the time. Nervous about an upcoming performance or a big date (i.e., psychological cause), and so you get an upset stomach (i.e., physical symptom)? Financial stress or work stress (i.e., psychological cause) giving you a splitting headache (i.e., physical symptom)? Honestly, people. Given the complexity of the human brain, it is utterly preposterous that all ailments are due to a physiological cause. Anyone who doctor shops enough will find someone who will eventually render a medical diagnosis (no matter how random or “rare”) that suits their PSYCHOLOGICAL need to have a medical explanation rather than a psychological one. Whenever I hear people maligning the “it’s all in your head” comment, I think to myself, “where else would it be?? OF COURSE it’s all in your head. that’s where the most complex organ in your body sits.”

Matt Evans New Jersey
..There is a fifth dimension, beyond that which is known to man. It is a dimension as vast as space and as timeless as infinity. It is the middle ground between light and shadow, between science and superstition. – Rod Serling

If conversion disorder makes sense, so does schizophrenia

Bear with me while I try to collect my thoughts on why the opinion of this medical doctor on conversion disorder in a New York State high school should equally apply to the percentage of the population diagnosed with schizophrenia. You can read the full article here.

CNN–Dr. Charles Raison, CNNhealth’s mental health expert, is an associate professor of psychiatry at the University of Arizona in Tucson.

Below I have extracted what Dr. Raison says about conversion disorder. Would he, using his own logic*,  agree with me that he could be talking about schizophrenia? No, of course he wouldn’t agree with me. Schizophrenia is always a special case to a psychiatrist, isn’t it?

  • strange behavior
  • no neural abnormalities
  • not manufacturing the problem
  • completely incapacitated by symptoms
  • makes psychological sense
  • age of onset often in teenage years

What is lacking in the diagnosis of schizophrenia, as opposed to the much rarer conversion disorder diagnosis, is “hope.” The medical community is resoundingly united in its prediction that the girls in New York State will make a complete recovery. This is great news for those girls and their families! Now, how about the much larger population of those diagnosed with schizophrenia being given the same good news?

Dr. Raison
When I teach psychiatry to medical residents, the first thing I tell them is that patients’ stories always make sense. No matter how bizarre a person’s symptoms might be, our lives follow a human logic, and they follow a medical logic. When a story doesn’t make sense, it means you don’t know the real story.Medical stories that don’t make sense are often big news makers, precisely because they don’t make sense. Sometimes, they titillate our hunger for the unexplained. Sometimes, they capture our attention because the medical uncertainty frightens us. 

The essence of a conversion disorder is the development of a neurological symptom — such as the tics seen in the young people of Le Roy — for which no neural abnormality can be found. Typically, a simple neurological exam will confirm that the symptom doesn’t result from any type of brain or nerve damage. And yet patients with conversion disorder have no conscious sense that the symptom is a production of their brains. That is, they are not manufacturing the problem. They are truly afflicted, and it can be horrible.

Only someone who has hypnotized people paralyzed for months and had them hop out of bed and run around the hospital room, or who has conducted “truth serum” interviews of people unable to speak, only to have them erupt into King’s English, would believe that such bizarre conditions exist. But having conducted these interventions, and more, I can assure you that people can be completely incapacitated by symptoms with no obvious medical cause.

Read more here.


* his surname is French for “reason” 

Conversion disorder not about mould

Le Roy, New York (CNN)Twelve female students from Le Roy Junior Senior High School in upstate New York are experiencing a mysterious medical condition. Their symptoms include stuttering, uncontrollable twitching movements and verbal outbursts.

Health officials say the symptoms are consistent with “conversion disorder.”

Dr. Jennifer McVige, a pediatric neurologist at the DENT Neurologic Institute who is treating many of the students affected, said, “Conversion disorder is a physical manifestation of physiological symptoms where there is traditionally some kind of stress or multiple stressors that provoke a physical reaction within the body.” McVige said the symptoms are real. “This is unconscious. It is not done purposefully.”…

Officials at the school hired an independent third party to conduct mold and air quality tests but found no environmental cause for the girls’ illnesses. A statement posted on the school’s website said, in part, “The medical and environmental investigations have not uncovered any evidence that would link the neurological symptoms to anything in the environment or of an infectious nature.”

Sanchez’s mother, Melissa Phillips said she does not agree. “I don’t think that all physical aspects of this have been exhausted; not enough testing has been done.”

The media reaction is to express “surprise” that this puzzling phenomenon can’t be traced to a contaminant in the physical environment, just like the medical community continues to be “puzzled” about the lack of clear cut medical evidence for schizophrenia. Here’s what the media should say about conversion disorder, but shies away from:

Conversion disorder: the modern hysteria
Colm Owens and Simon Dein

Conversion disorder is thought to occur primarily in societies with strict social systems that prevent individuals from directly expressing feelings and emotions towards others. Temporary somatic dysfunction is one possible mode of communication, particularly for those who are oppressed or underprivileged. The ‘psychological mindedness’ and ease of emotional expression typical of modern developed societies have led to the increasing rarity of conversion disorders in developed countries (Tseng, 2001

Conversion has been attributed to many different mechanisms. One influential theory, dating back to Ancient Greek physicians who thought the symptoms specific to women, invoked as their cause the wandering of the uterus (hustera), from which the word hysteria derives. The term conversion was first used by Freud and Breuer to refer to the substitution of a somatic symptom for a repressed idea (Freud, 1894). This behaviour exemplifies the psychological concept of ‘primary gain’, i.e. psychological anxiety is converted into somatic symptomatology, which lessens the anxiety and gives rise la belle indifference, where a patient seems surprisingly unconcerned about their physical symptoms. The ‘secondary gain’ of such a reaction is the subsequent benefit that a patient may derive from being in the sick role.

As David & Halligan (2000) point out, the concept of conversion disorder has raised great controversy between the proponents of psychological and physiological models of mental states. Conversion disorder raises the intriguing philosophical problem of how it is that psychological or mental states can effect long-term motor, sensory and cognitive changes in people claiming not to be consciously responsible for them. Theories falls into three main groups: psychoanalytic, learning theory and sociocultural formulations

Psychoanalytic theories

Psychoanalytic explanations of conversion disorder emphasise unconscious drives, including sexuality, aggression or dependency, and the internalised prohibition against their expression (Hollander, 1980). A classic paradigm of this theory is the case of Anna O., who was treated by Freud (Breuer & Freud, 1895). Physical symptoms allow for the expression of the forbidden wish or urge but also disguise it. Other psychoanalytic explanations focus on the need to suffer or identification with a lost object (Ford & Folks 1985). An analytic therapist would attempt to treat a conversion disorder by helping the patient move to more mature defence mechanisms.


It is crucial in any approach to patients with conversion disorder to establish a therapeutic alliance and to allow recovery with dignity and without loss of face. It is important that nursing and medical staff avoid labelling these individuals as manipulative, dependent or as exaggerating their difficulties.

Read the rest here