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

The Chalk Garden

Chris and I went to see The Chalk Garden Friday night, our local expat production. Ian was out of town and Alex has a girlfriend to occupy his time, so it was just the two of us. Putting aside the weak acting, the message was interesting.

The Chalk Garden had its debut on Broadway in 1955. The setting is an English country house owned by an exceedingly wealthy woman who is parenting her sixteen year old granddaughter Laurel. They have a conscientious objector manservant and an incapacitated butler who lives upstairs. The play opens as new governesses are being interviewed to take charge of Laurel. No governess has stayed for long because, among other things, Laurel sets fire to things. Laurel also delights in telling anyone in earshot that her father committed suicide when she was twelve, she was sexually molested in a park around that time as well, and her mother has remarried for “love!” Laurel is, as we say nowadays, a “piece of work.”

The grandmother thinks Laurel is delightful and humors her. “Apart from a few fixations with fire, she’s a charming girl,” she insists. The greatest sin it appears, in the grandmother’s eyes is to be boring. Other than that, the grandmother comes across as engaged, liking people, confident in her own judgment (she doesn’t ask for references), but not terribly introspective. In short, she seems relatively “normal.” She encourages Laurel to run amok and poke her nose into other people’s business. Today she would probably be referred to as an “enabler.”

The reserved new governess, Miss Madrigal, is obviously hiding something. She is a knowledgeable gardener and horrified that nothing will grow in the garden. All the wrong plants have been introduced into soil that is essentially chalk. She catches on to Laurel rather quickly. Laurel’s mother makes a couple of attempts to visit and she and the grandmother quarrel constantly. She wants to take Laurel back to Suez live with her, her new husband, and Laurel’s soon to born be half-sibling.

The play was written in an era when people were fascinated with Freud’s theories. What I find interesting is that it wasn’t a heavy-handed caricature of motherhood, sex and secrets, but rather how obviously people can overlook problems brewing in children. Many parents want their children to be interesting, even a little bold, we often give them a long leash while they are growing up and we expect them in the end to come around. Parents are stereotypically portrayed as spirit crushing tyrants, but I feel this play shows the other side of child rearing that will often lead to problems in adulthood if tolerated. Laurel’s problems are an exaggeration of more benign traits in children that can still prove to be problematic in adulthood.

The action in the play really picks up when the grandmother’s old flame, the Judge, comes for luncheon. He’s seventy-five years old and still presiding at the criminal court. Laurel, the manservant and the butler are fascinated by murder cases. Laurel cleverly figures out during the luncheon that Miss Madrigal has appeared before the judge at some point in the past, and it quickly becomes evident that Miss Madrigal was tried for a murder. She was originally sentenced to death but the sentence was commuted to fifteen years solitary confinement. Miss Madrigal feels very strongly that she was unjustly convicted, since she had, for the first time in her life, told the truth, but neither the judge nor the jury wanted to hear it. So to jail she went, narrowly avoiding execution.

Time in solitary confinement has given Miss Madrigal time to change who she is, not just in hiding her past, but in her newfound commitment to truth. If she doesn’t get to Laurel, she, of all the people there, knows where lying can lead. She won’t give it a pass as just something Laurel will grow out of. She confronts Laurel about the incident in the park, and sure, enough, it didn’t really happen, and Laurel’s father died of liver failure, not suicide, when Laurel as three, not twelve. Miss Madrigal literally forces Laurel to leave for Suez with her mother, because she knows that Laurel will not grow in this house.

I remember when I was in my twenties reading in the newspaper of a girl I had gone to elementary school with, who was sent to jail for bank embezzlement. I hadn’t thought of this girl for years until I saw the headline. The first thing I remembered about her was that even back in third grade, you couldn’t trust anything she said. Her family probably thought she would grow out of this, too.

Chris’s “problems” in childhood flew under our radar screen. He was an intelligent child who did his best to remain invisible. He didn’t bother working in school, yet managed to do okay. Mathematics, the perennial Achilles heel up for a lot of students, wasn’t a problem for him. He simply didn’t try to excel, which Ian and I overlooked as typical of boys. We assumed he would clue in later. No teacher ever called us to say that Chris was having problems, academic or social. His problem from my perspective even then was that he was kind of invisible and he wasn’t putting himself out there in the game of life. Do parents drag their child to a psychologist with the complaint that he’s kind of bland and not putting himself out there? This is the opposite of Laurel’s problem. Laurel’s issues are nowadays the kind that are more likely to be brought to the attention of psychologists.

Would a psychologist have been able to do anything about my concerns? Maybe, maybe not. Would a psychologist have even seen where this could lead? I don’t know. If I knew then what I know now, I would have paid more attention to helping Chris come into himself and looked within myself more for its cause. I would have needed some help because I just didn’t see the dark side of this.

Shit: biochemical or psychological?

Chris was packed off to the hospital with all his vitamin supplements. I left instructions with Dr. Stern to confer with Dr. X, the head of the unit, to make sure that Chris received them three times a day. I felt that all the progress that Chris had made would be quickly overturned if he was yanked off the supplements in favor of antipsychotics. Dr. Stern conferred with Dr. X about making this accommodation. He agreed, which was rather refreshing. Refreshing, yes, but suspicious. I sensed it would be a only matter of time before pressure mounted to get rid of the vitamins.

“I have such hate” said Chris glumly when I visited him a few days later. I bet he did and I was glad he admitted it, but I said nothing. Chris continued to urinate and defecate in his pants. The nurse informed me that the other young people were avoiding Chris and making fun of him, so they suspended his vitamin intake for a couple of days to see if this would stop the problem. I suggested to her that maybe his soiling his pants was a sign of anger and not a vitamin problem. For heaven’s sake, we are in a psychiatric hospital – within these walls shouldn’t shit be viewed as the deeply rooted psychological problem that it is? Instead, shit seems to be merely a biochemical end-product. What ever happened to Freud?

The French word for anger is “colère”, in keeping with the words “cholera” and “melancholy”, and is linked to the body’s production of choler or black bile, one of the four ancient humours. Referring to black bile, Robert Burton, in The Anatomy of Melancholy, first published in 1621, observed that “there is no nook or cranny of the mind into which this ‘roving humour’ has not insinuated itself. It is ‘inbred in every one of us.’” He explained that he wrote of melancholy to avoid being melancholy. The famous schizophrenic “apathy, flat affect and lack of motivation” is this not depression and melancholy? If we all have it to some extent, cannot each of us find some resiliency in us to crawl our way out of it?

Chris was aware that he would miss out on interacting with others of he didn’t clean up his act and he said so to me. He may have just been placating me, who knows? My opinion is that he would stop showing antisocial behavior when it was to his benefit to do so, not because the vitamins were temporarily discontinued.

Obviously, Chris’s health was too important to leave to the discretion of the hospital staff, so I smuggled his packages of supplements into his room and encouraged him to take them every day.

At our next meeting, Dr. X announced to us that Chris’s incontinence problem had cleared up, and so the decision to suspend the vitamin supplements had been the correct one. “Well, Dr. X”, I interrupted him, “I am sorry to tell you this, but Chris has been taking the supplements all along. The vitamins have nothing to do with Chris’s incontinence. Anger does.” Dr. X flushed briefly, then regained his composure. “Then, I guess, under the circumstances, Chris may as well continue to take his supplements,” said Dr. X, not unreasonably.

The German psyche

What is it about German speaking psychiatrists? The pantheon of psychiatry’s superstars includes Freud, Jung, Fromm-Reichmann, to name but three. I also have found that those who have most influenced my perception of schizophrenia tend to be German speaking: Daniel Paul Schreber, Dietrich Klinghardt, Bert Hellinger, and Geerd Hamer. Of course, I am stereotyping, but I believe that German thinkers understand the complex underpinnings of self better than most of us.

I read an interview recently in the Financial Times with Simon Rattle, the principle conductor and artistic director of the Berlin Philharmonic Orchestra. Mr. Rattle is British, but has observed the German temperament closely in his tenure with the orchestra. The interview brims with his astute observations. “The (German) necessity of rules and strictness is a way of dealing with an enormously powerful impulse: Germans are among the most emotional people on the planet. Maybe it has to do with the fact that as a nation they are always drawn back to nature and the forest.” He believes that concept of German precision is a “self-imposed correction to the German psyche. Without it there would be complete chaos, because everyone is so emotional.”

Ergo, the German psyche is therefore well suited to understanding schizophrenia.

“Maestro Chef”, Interview with Sir Simon Rattle, Financial Times, June 20/June 21 2009