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Rapid Responses: Rapid Responses published:
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Questionable assumptions
- Daniel R Hicks (20 October 2005)
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Hysteria or conversion disorder?better diagnosis because of modern technology.
- AK Al-Sheikhli (20 October 2005)
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misdiagnosis of conversion symptoms and hysteria- one aspect of the wider picture
- Yatan PS Balhara (21 October 2005)
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Another explanation
- John F Corish (29 October 2005)
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? Disease
- Mainak Mukherjee (1 November 2005)
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Diagnosis is not pervasive
- Mohammed Usman (2 November 2005)
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Decline in conversion disorders and increased cases of depression
- James Paul Pandarakalam (3 November 2005)
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Misdiagnosis
- Neil M Davidson (3 November 2005)
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Converts to conversion?
- M E Jan Wise (4 November 2005)
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Misdiagnosis of hysteria and histrionic personality disorder
- Sepideh Omidvari (7 November 2005)
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Profile of Conversion disorders among children
- Pravija T Manikoth (7 November 2005)
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misdiagnosis of conversion symptoms and "hysteria"
- Dr Pramod Koyee (22 November 2005)
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Re: Misdiagnosis of conversion symptoms and hysteria-impact of service improvement
- Charles N Antwi (24 November 2005)
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Daniel R Hicks, Programmer IBM Rochester MN USA 55901
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As someone who has suffered most of my life from an (until recently) undiagnosed disorder, I find a couple of things questionable in this review. First, since it's not uncommon for people with disorders such as POTS or post-polio syndrome to go for 3-5 years (and sometimes much longer) without diagnosis, any followup for less than 5 years is suspect. If one observes the length of time of followup in the cited studies, there appears to be a general tendency for later studies to have shorter followups, introducing a bias towards underestimating the rate of misdiagnosis. Second, it's been frequently observed that insanity is repeating the same thing again and again and expecting a different result. In my correspondence with folks with disorders such as POTS it frequently appears to be the case that they do not achieve a correct diagnosis until they change doctors. This doesn't imply that docs are pig-headed (though that's certainly a good topic for another study) so much as it implies that they either lack the experience/knowledge to make the diagnosis or have trouble achieving a degree of objectivity once the first diagnosis has been made. In fact, in many cases once a diagnosis had been made the patient is likely to cease pursuing other possibilities, and, unless something occurs to force a reevaluation, an incorrect diagnosis is apt to "stick" for decades. Fibromyalgia would be a classic example of this -- once the diagnosis has been made and the patient accepts its chronic nature, any other diagnosis becomes virtually impossible. So any study that uses the same clinical organization for both initial diagnosis and followup and which doesn't include an objective (3rd party) rediagnosis in the followup is almost certainly going to understate the rate of misdiagnosis, possibly quite severely. It would appear that, to achieve credible reliability, a study needs to use a sort of "capture/recapture" sampling technique, where patients would be reevaluated multiple times so that the rate of misdiagnosis during followup could be better estimated. Competing interests: None declared |
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AK Al-Sheikhli, Loc.Consultant Psychiatrist MRCPsych DPM
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EDITOR, It was an excellent review of hysteria by Stone et al [BMJ,doi:10.1136/bmj.36628.466898.55]. I must admit that the great impact on my work at personal level was the paper of Slater, diagnosis of hysteria [BMJ,1965;1395-9] Competing interests: None declared |
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Yatan PS Balhara, resident, department of psychiatry all india institute of medical sciences, new delhi , india, 110029
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Conversion disorders (as per DSM IV) and dissociative disorders/ conversion disorders ( as per ICD- 10)have long been associated with a rather uneasiness of use by the treating mental health professionals. The possible reason could be the clause that "the possible organic cause of the condition must have been ruled out befoe making the diagnosis". the definition of organicity has always been confusing in the field of psychiatry. When simple roentgenogram of the head was available it meant the investigation to rule out organicity, on ite arrival CT scan became the investigation of choice, MRI took the spot on its introduction, which now is giving way to SPECT and PET and MRS among others. And by any stretch of imagination it must not be more than a few more years before we have another new gold standard purely because of better resolution power. Most of the psychiatric disorders have long being considered as functional, something that is beyond organicity. but the underlying basis of this so called 'functional' nature of these disorders may be the lack of the sensitivity of the available investigational tools available. With the availability of techniques with higher resolution people are coming up with the findings in the brain of patients with psychiatric illness- be it schizophrenia, mood disorders, anxiety disorders or even hyteria/ dissociative/ conversion disorders. Its hard to draw a boudry as a cut off for organicity. May be what is functional today would become organic in very near future- would the condition then become "organic" and no longer be "functional" and would it become a prerogative of a neurologist and not a psychiatrist to manage such cases merely on the basis of such findings. Probably thinking beyond the investigational findings would yield a better perspective of looking at these disorders and probably better patient care. Another important aspect to keep in mind while dealing with individuals with symptoms resembling neurological disorders with or with out positive radiological investigational findings is the liklihood of coexistance of the two conditions. A patient with a diagnosis of conversion disorder is in no way immune from getting an organic condition manifesting with similar findings later in life. Similarly, the organic conditions may be colored by the presence of a functional component. For optimum management of the patient one has to keep in mind all these possiblities and should not give the benifit of neurological care to a patient with a previous diagnosis of conversuoin disorder or of psychiatric cate to on e with a previous neuroogical illness. I would like to highltight one such case presenting to us to emphasise the point.- Mrs. Y, a 75 yr. old lady presents with the complaint of altered sensorium for the past two days. She is behaving rather strangely according to them. She is not accepting any meals and her spontaneous moments have been gradually decreasing over the last two days. Since today morning she has also started losing control over her bladder and bowel. Mrs. Y is a diagnosed case of conversion disorder since the age of 25. She was married against her wish and was not welcome by her husband and in-laws for her “not so good looks”. After three years of marriage she started experiencing episodes of abnormal body movements followed by phases of unresponsiveness lasting from 15 to 20 minutes. She continued to experience similar spells for the next 35 years without any significant change in a family dynamics. Never ever during these 35 years she experienced incontinence or tongue bite; neither would she sustain any significant physical injury following falls during these spells. She was shown to a number of psychiatrists and psychologists but her condition remained more or less similar. For the past 15 years the family members observed some changes in these spells. Now at times the patient would pass urine in her clothes and would also sustain tongue bite during some of the spells. She would also sustain physical injuries during these episodes and has got five fractures over these years. These features would be nothing more than “newer manifestations of previous spells” for the family members and they would not seek any further medical consultations apart from those of the orthopaedician. Two days back the patient had one similar spell during which she sustained injury over head. CT scan head revealed a subdural hematoma. Association of seizures and pseudo seizures is a well-recognized medical phenomenon. Presence of co morbid neurological illness in the case of conversion disorder has been fallen to be up to 70%. Usually pseudo seizures have been associated with pre-existing seizure disorder. However, the reverse phenomena should also be kept in mind and family members need to be psycho educated about its possibility, so that no patient is deprived of the due care. Mrs. Y, a diagnosed case of conversion disorder continued to experience complications of a seizure disorder for around 15 years because of the ignorance of the family members. Psycho education can prove to be an effective tool in proper management of such cases. References- 1. Sadock and Sadock. Comprehensive text book of psychiatry, 7th edition. Lippincott Williams and Wilkins. 2. Jon Stone, Roger Smyth, Alan Carson, Steff Lewis, Robin Prescott, Charles Warlow, and Michael Sharpe Systematic review of misdiagnosis of conversion symptoms and "hysteria" BMJ 2005; 0: bmj.38628.466898.55v1 3. DSM IV- Diagnostic and statistical manual for the diagnosis of mental disorders. 4. ICD- 10 International statistical classification of mental and behavioural disorders. Competing interests: None declared Editorial note
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John F Corish, Medical Practitioner Dublin 15, Ireland
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I find it puzzling that a paper purporting to be a systematic review of cases misdiagnosed as hysteria or conversion disorder fails to refer, even briefly, to the complex history of this neurosis. In their discussion the authors write: "In the study of misdiagnosis of conversion symptoms or hysteria the overall pooled proportion for the whole period was 8.4% (7.1% to 9.9%). This overall figure, however, disguises a change over time from 29% in the 1950s and 17% in the 1960s to a consistently low rate of 4% for every decade since then." The drop from 29% in the 50's to 4% over the past three decades seems dramatic. However, the drop more or less coincides with the precipitous fall from grace in psyciatry of psychoanalytic schools of thought and the emerging dominance of biological psyciatry that occurred in the mid 60's. Thus, the high rates of misdiagnosis that are alleged to have occurred in the 50's are not so remarkable if one considers that this diagnosis was much more frequently invoked then than it is today. Indeed, I suggest that we have gone full circle and that many conditions now being diagnosed as organic are in fact functional. I look forward to reading the review article on this phenomenon in the October edition of the BMJ in 2045. Competing interests: None declared |
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Mainak Mukherjee, Consultant Psychiatrist West Bengal, India, 713101
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'We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease'... What is meant by 'disease' here? Is conversion disorder not a disease? Competing interests: None declared |
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Mohammed Usman, SHO Psychiatry Leeds Mental Health NHS Trust, Horizon Centre, Wakefield WF1 4SP
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Dear Sir / Madam I read with great interest the "Systematic review of misdiagnosis of conversion symptoms and "hysteria". It is fairly established that people with " functional" symptoms, later on have been diagnosed with an " organic" disorder.This article does indeed further this observation. The dramatic fall in the rates of "misdiagnosis" could be attributed to the current socio-political culture.With the looming threat of legal battles, i would be very reluctant to make this particular diagnosis.Its not surprising that the diagnosis rates have fallen. I would be very interested to know if there s a relationship between the initial symptoms and the later diagnosis.One should not forget that psychiatric diagnosis are not a label for the rest of ones life. But only points to the then prevailing mental health problems. Thank You for considering my views Mohammed Usman
Competing interests: None declared |
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James Paul Pandarakalam, consultant psychiatrist, 5 Boroughs Partnership NHS Trust St Helens North CMHT, Peasley Cross Resource Centre, St Helens, Merseyside WA 9 3DA
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The concept that unresolved tension due to psychological conflicts are either transferred to parasympathetic system causing psychosomatic diseases and to muscular system leading to conversion reactions still holds water. Egyptians recognised “wandering uterus” as early as 2000 B.C but Paul Briquet described it as the disorder of dysfunction of the C.NS. in the 19th century and Freud used the word conversion disorder to refer to the substitution of a somatic symptom for a repressed idea. Ever since the discussion of Freud’s Dora case, many a “phantom disease” came to be hidden under the rubric of conversion disorders and some of such conditions are now getting diagnosed differently with the modern technology. The laymen’s psychiatric vocabulary has improved: patients are in a better position to articulate their distress and this has probably resulted in the decline of conversion disorders. Many of the potential conversion disorders are now presented as straightforward cases of depression. True cases of conversion disorders still exist. As a whole, conversion disorders are characterised by sensory, motor or visceral symptoms and the commonly missed symptom related to diseases are gait and movement disorders .1 Hoover’s contralateral leg sign is currently less talked about in the academic circles but still useful in diagnosing hysterical hemiplegia from true cases of hemiplegia. This is demonstrated by placing the palm underneath the ankle of the affected lower limb and asking the patient to raise the unaffected limb; the examiner could feel the pressure in the palm in the case of a true case of hemiplegia. 1.Stone John et al. Systematic review of misdiagnosis of conversion symptoms and “ hysteria” B.M.J. 2005; doi 10.1136/bmj. 38628.466898.55 Competing interests: None declared |
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Neil M Davidson, Medical Director, Reddington Multi-specialist Hospital Lagos, Nigeria
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I was interested to read your paper on misdiagnosis (BMJ (2005) 331, 989) - but whose basis is itself erroneous, inasmuch as the misdiagnosis is surely that of epilepsy, movement disorders, multiple sclerosis etc as conversion symptoms, and not vice versa.
Competing interests: None declared |
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M E Jan Wise, Consultant Psychiatrist 13-15 Brondesbury Rd, London NW6 6HX
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Editor: Stone et al (1) have significantly added to the credibility of conversion disorders. The role of illness behaviour in symptom presentation is often overlooked, with professionals neglecting the influence of secondary gain. The role of advocate and healer has rightly been foremost in the minds of doctors. However recent research in the areas of disability and somatisation has highlighted the poor ability of doctors to detect symptom exageration (2). Over 40% of patients with Chronic Fatigue making claims for disability fail tests of memory which are passed by those with pentrating brain injuries or dementia severe enough to require 24 hour care (3). Increased use of psychological testing helps detect such inconsistencies in performance. Perhaps with increased use of psychometric tests we will diagnose these psychosomatic disorders with greater skill, and possibly frequency, reducing unneccessary investigations, and improve health outcomes by providing the right treatments. 1 Stone, J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ 2005;331:989-91. 2 Green, P., Lees-Haley, P.R. & Allen, L.M. (2002) The Word Memory Test and the validity of neuropsychological test scores. Journal of Forensic Neuropsychology, 2, 3 / 4, 97-124. 3 Gervais, R.O., Russell, A.S., Green, P., Allen, L.M., Ferrari, R. and Pieschl, S D. (2001) Effort testing in patients with fibromyalgia and disability incentives. Journal of Rheumatology, 28, 1892-1899. Competing interests: Chairman of the BMA's Medico- Legal Committee |
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Sepideh Omidvari, Psychiatrist, Assistant Professor Iranian Institute for Health Sciences Research, Tehran, Iran
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In a systematic review Stone and colleagues (1) indicated misdiagnosing symptoms of non-psychiatric diseases as conversion disorder happened in about a third of patients diagnosed with "conversion symptoms" in the 1950s but had fallen to 4% by the 1970s and has remained steady since then. Misdiagnosis was most common in patients with gait or movement disorders and a psychiatric history. However, some points are posed. 1. According to DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) there is a pervasive pattern of excessive emotionality and attention seeking in people with "histrionic personality disorder" indicating by displaying rapidly shifting and shallow expression of emotions, a style of speech that is excessively impressionistic and lacking in detail, showing self- dramatization, theatricality, and exaggerated expression of emotion. It seems the signs may lead to histrionic patients' poor definition and exaggerated presenting symptoms and physicians' neglecting the valuable serious signs, preparing the way for misdiagnosis of conversion disorder in medically ill people. 2. Factitious disorder, direct effects of a substance and a culturally sanctioned behavior or experience need to be considered in addition to general medical condition and malingering in the differential diagnosis of conversion disorder according to DSM-IV-TR. 1) Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, and Sharpe M. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ 2005; 331: 989. Competing interests: None declared |
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Pravija T Manikoth, Clinical Observer, Department of Psychiatry. Neath Port Talbot hospital, Baglan Way, Port Talbot, SA12 7BX
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The article ‘Systematic review of misdiagnosis of conversion symptoms and "hysteria" ` was highly informative. However, I was disappointed to see that paediatric population was totally excluded from the analysis. In comparison to evidences on adults, there is a relative scarcity of data on paediatric conversion disorders. The available literature shows that children with ‘medically unexplained symptoms’ form a notable proportion of cases in child guidance and psychiatry clinics.1 The symptom profile is also complex, ranging from pseudoseizures and gait disturbances to pseudoaerophobia.2 Though reported to be rare in children less than 10 years,3 I have come across a case of conversion in a child under 10. Previous studies have also suggested that such reactions could be linked to previous traumatic experiences,4 and these children are at increased risk of developing subsequent psychiatric morbidities (eg. mood and anxiety disorders) in later life.5 Improved social services delivery system may have a positive impact on the prevention of these disorders. All these warrant more multicentric studies to analyze the recent trends in the diagnosis and outcome of paediatric conversion disorders. References: 1.) Srinath S, Bharath S, Girimaji S, Sheshadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry. 1993 Jul;32(4):822-5 2.) Anand MR, Krishnakumar P. Conversion disorder presenting as Pseudohydrophobia (Letter to Editor). Indian Pediatrics 2004; 41:1284-85. 3.) Lehmkuhl G, Blanz B, Lehmkuhl U, Braun-Scharm H. Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence. Eur Arch Psychiatry Neurol Sci. 1989;238(3):155-60. 4.) Diseth TH. Dissociation in children and adolescents as reaction to trauma--an overview of conceptual issues and neurobiological factors. Nord J Psychiatry. 2005;59(2):79-91. 5.) Brasic JR. conversion disorder in childhood. German journal of psychiatry.2002;5(2):54-61. Competing interests: None declared |
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Dr Pramod Koyee, Trainee Psychiatrist North Linconshire PCT
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The paper on Systematic review of misdiagnosis of conversion symptoms and "hysteria” is very relevant and findings are significant though it has some limitations like majority-retrospective study design and in patient setting. I believe that the result of this analysis will help to reshape the traditional teaching on this topic. However, the authors have said that improvement in the study design is the main reason behind the falling percentage of misdiagnosis, which I think is not quite true. I believe the main reasons behind improving the misdiagnosis is increasing awareness and knowledge among the medical profession about the misdiagnosis after the landmark study of Slater ET 1965. Hence positive approach and better care of patients are the main reasons behind the decreases in the rate of misdiagnosis of conversion disorder. References: 1)Jon Stone, Roger Smyth, Alan Carson, Steff Lewis, Robin Prescott, Charles Warlow, and Michael Sharpe Systematic review of misdiagnosis of conversion symptoms and "hysteria" BMJ 2005; 0: bmj.38628.466898.55v1 2)Oxford Texbook of Psychiatry 3)DSM IV- Diagnostic and statistical manual for the diagnosis of mental disorders. 4ICD- 10 International statistical classifications of mental and behavioural disorders Competing interests: None declared |
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Charles N Antwi, Senior House Officer, Psychiatry Wonford House Hospital, Dryden Road, Exeter EX2 5AF
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EDITOR- The article “Systematic review of misdiagnosis of conversion symptoms and "hysteria" by Stone et al., is very relevant to current medical and psychiatric practice. The significant decline in the misdiagnosis rate of conversion disorder is probably an indicator of improved psychiatric services, alongside with increased physician awareness of medically unexplained symptoms. Liaison Psychiatry service is currently being proliferated in most acute medical trusts. Liaison psychiatry is a psychiatric subspecialty, which provides psychiatric treatment to patients attending general hospitals, whether they attend out-patient clinics or accident & emergency departments or are admitted to in-patient wards. It thus deals with the interface between physical and psychological health. There is now abundant evidence that medical and surgical patients have a high prevalence of psychiatric disorder which can be effectively treated with psychological or pharmacological methods. It is probable, that these days physicians tend to involve psychiatrists as part of the multidisciplinary team more than in the past. A robust multidisciplinary team is less likely to misdiagnose. A recent article in the BMJ reviewing medically unexplained symptoms, suggests that every neurology service should have easy access to referral to specialist liaison psychiatry. Moreover, there is increasing awareness and availability of various treatments for mental disorders. The National Service Framework for Mental Health includes standards which promote mental health, primary care and access to services, as well as effective services for people with severe mental illness. Thus individuals experiencing stress or psychological conflicts are more likely to receive professional psychological help earlier, thereby reducing the chances of development of conversion and dissociative disorders in predisposed individuals. A reduction in number of patients presenting with conversion disorders would probably minimize misdiagnosis. I hope this contribution is useful.
References: 1) Götz M, House A, Every neurology service should have access to specialist liaison psychiatry, BMJ 1998;317:536 2) Dawson AM. The psychological care of medical patients: recognition of need and service provision. London: Royal College of Physicians and Royal College of Psychiatrists , 1995. 3) National Service Framework for Mental Health,Department of Health Competing interests: None declared |
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