18 - Dissociative [conversion] disorders

Summary

General considerations, definition and classification

The term ‘conversion’ (Freud, 1894) was originally used to describe the process whereby psychic energy contained in an instinctual wish is transformed – or ‘converted’ – into physical symptoms. Conversion symptoms are thus a symbolic representation of repressed instinctual wishes. Psychic equilibrium is restored at the price of a mismatch between the severity of symptoms and the indifferent attitude of the affected individual towards the symptoms (‘belle indifference’). Conversion symptoms are closely related to hysteria. However, in recent years the term hysteria has not only been used in the psychoanalytic sense, but increasingly in a phenomenological and descriptive sense. In the 1920s, hysterical symptom neurosis (conversion) was distinguished from hysterical character (hysterical character neurosis). However, this classification is not precise and allows only a rough distiction, because conversion symptoms also occur frequently in hysterical personalities.

Classification

In the last few years, attempts have been made to distinguish between the disparate symptoms associated with the term hysteria. In ICD-10 the term ‘hysteria’ is avoided ‘in view of its many and varied meanings’ (WHO, 1992). Instead, three different categories associated with the concept are described:

1. (i) dissociative [conversion] disorders (F44), e.g. dissociative amnesia, dissociative stupor, dissociative convulsions;

2. (ii) somatoform disorders (F45), e.g. somatization disorder, hypochondriacal disorder, somatoform autonomic dysfunction, persistent somatoform pain disorder;

3. (iii) histrionic personality disorder (F60.4), which is simalar to the classic ‘hysterical personality’.

In the following section only those conversion symptoms or hysterical disorders relevant to childhood and adolescence are discussed.