ISSN- 0301-1216

Indian J. Prev. Soc. Med. Vol. 42 No.3, 2011

A COMPARATIVE STUDY OF PSYCHOSOCIAL FACTORS IN MALE AND FEMALE PATIENTS OF CONVERSION DISORDER Anuradha1, Mona Srivastava2, Manushi Srivstava3
ABSTRACT
Background: Conversion disorder develops as a reaction to emotional stress or conflict in presence of a series of environmental, biological and personal vulnerability factors or as a part of the current life situation. This study was carried out to determine the nature and pattern of stressors causing the disorder and to compare the same in both sexes Methods: This study was carried out at Psychiatry department of a teaching hospital in Uttar Pradesh. Forty subjects satisfying the inclusion and exclusion criteria were selected from the OPD and indoor services of the hospital, the patients were consecutively selected. They were interviewed and assessed on HARS, HDRS, PSLES and a semi-structured pro forma for family functioning, and the results were analysed. Results: Stressors were clearly identified in (90%) subjects and ranged from disturbed relations with in-laws, engagement/marriage against wishes, disturbed relations with spouse, husband staying abroad, conflict with parents, conflict at work, failure in exam/study problem, love problems, death of spouse, and threat to life. Conclusions: We concluded that stressors were present and identifiable in most of our subjects. The pattern of stressors in our subjects was unique to our population and most of these stressors were easily treatable, the long term and short term stressors differed in both sexes. Key Words: Hysteria, Conversion disorder, DSM-IV, HAM-A (Hamilton Anxiety Scale), HDRS (Hamilton Depression Rating Scale), PSLES (Presumptive Stressful Life Event Scale), Stressors, Psychosocial factors.

INTRODUCTION
Conversion Disorder develops as a result of emotional stress/conflict in the presence of series of environmental, biological and personal vulnerability factors in the context of current life situation
1

.Till recent times it was called by the word

hysteria and was considered to be a female illness, however the concept has undergone a revolutionary change and males are also found to be affected, albeit in a lesser proportion, however, it is seen to be steadily increasing in this part of population . Hysteria is one of the oldest words in the medical vocabulary . It is derived from Greek word Hysterus meaning wandering of uterus in the body . Galen rejected the idea of wandering uterus and suggested that the abnormality was due to undue retention of uterine secretions. Since then hysteria has been a topic of interest in medicine . Writings of Freud also contributed in generating interest in this disorder. The concern about hysteria is evident from the fact that the aetiology, pathophysiology and even nomenclature have been rapidly changing throughout the known history of medicine, and psychiatry in particular . _______________________________ 1. 2. 3. Medical Social Worker, Deptt.of Psychiatry, Institute of Medical Sciences, BHU, Varanasi, India.221005 Asst. Professor, Deptt. Of Psychiatry, Institute of Medical Sciences, B.H.U., Varanasi, India.221005 Assistant Prof., Dept. Of Community MedicineInstitute of Medical Sciences, BHU, Varanasi, India.221005
5 4 3 1 2

Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB &
Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.

Anuradha et al

A comparative study of psychosocial factors in male and female patients of conversion disorder

However, with advance in knowledge, skills and after observing multiple cases, the aetiology, nomenclature, nosology, prevalence, sex discrimination and even symptomatology have been revised
6 4,5

. Briquet and Charcot contributed to the

development of the concept of conversion disorder by noting the influence of heredity on the symptoms and the common association with a traumatic event . Now it is suggested that hysteria develops as a reaction to emotional stress or conflict in the presence of a series of environmental, biological and personal vulnerability factors or as a part of the current life situation . Current diagnostic criteria (DSM-IV) requires that stressors must be associated with the onset and course of psychological symptoms rather than paying attention to hypothetical psychological mechanism involved in the aetiology of conversion disorder and the term hysteria has been replaced by the term conversion disorder . Stress occurs when people are faced with events or situations they perceive as endangering their physical or psychological well being. These events are usually referred to as 'stressor' and the people's reactions to them as 'stress response'. These stressors which are perceived usually fall into one or more of the following categories: traumatic events, uncontrollable events, unpredictable events or events challenging the limits of ones capabilities and self -concept . The stress reaction includes autonomic responses, endocrine changes & psychological response . The patient uses various coping mechanisms to adapt to the stress. The personal experience of illness in relatives or friends determines the course of signs and symptoms. These sign and symptoms mimic organic disease and allow the patient to adopt sick role with consequent relief from precipitating stress or conflict
10 9 8 7 1

.The Conversion disorder is classified in the group along with Dissociative disorders
7

and Somatoform disorders and requires the presence of a stressor . An increase in the number of cases of this disorder can be attributed to the fact that our society accepts physical manifestation of an illness; hence these symptoms can be viewed as an adaptive way of functioning under stressful situations
11

There is a huge body of literature available regarding this disorder; however, there is a conspicuous lack of studies in males and practically none comparing the stressors in both the sexes. The search of the Indian database also revealed a lack of studies in this area; hence the present study was undertaken.

MATERIAL AND METHODS

The present study was undertaken to look at various stressors in male and female subjects which precipitate the conversion disorder, to compare the order of importance of the stressors in both the sexes and to study the psychological/ social/familial factors which form a part of stressors in the conversion disorder patients. Subsequent patients fulfilling DSM IV
7

criteria for conversion disorder were taken from Sir Sundarlal Hospital of I.M.S.; B.H.U. Varanasi.The diagnosis was made by
7

a psychiatrist (MS). The subjects who fulfilled the inclusion criteria formed the part of the study .The inclusion criteria were thus: diagnosis as per DSM IV , having no significant co-morbidity, no significant substance abuse, absence of an organic disorder. On intake a written informed consent was taken from the subjects, the study was also approved by the institute ethical committee. The subjects were examined by history taking, examination, if needed by investigations, there after they were administered the following tools: Hamilton Anxiety Rating Scale (HAM-A)
13 12

, Hamilton Depressive Rating Scale (HDRS)

, Presumptive Stressful life events Scale (PSLES)

14

, Family history on semi structured pro forma to assess the cases for

family jointed ness, communicative pattern, noise level and other areas of functioning was undertaken. In case of admission the subjects were examined in the wards, the data collection continued for a period of six months. Patients not fitting into DSM-IV
7

diagnostic criteria for conversion disorder, patients presenting with physical disorders (especially neurological

disorders), cases with an evidence of mental sub normality, cases with drug dependence and malingering cases were excluded. After data collection the results were summarized for age, sex, occupation, educational status, residential status (urban or rural), marital status, financial/socioeconomic status and presence of stressors, life events, nature of stressors, family functioning, depression and anxiety scores.

Indian J. Prev. Soc. Med Vol. 42 No.3

232

July-September, 2011

Anuradha et al

A comparative study of psychosocial factors in male and female patients of conversion disorder

Table-1: Socio Economic characteristics of the two groups

RESULTS
Forty subjects both male (n=20) and female (n=20) who fulfilled the inclusion and exclusion criteria were selected for the study. Table-I shows the socio demographic characteristics of the two groups, maximum number of the subjects belonged to the age group of18-25 years, females were usually married while equal number of single and married males were represented in the group, the educational status of the males was higher than the females. Most of the subjects belonged to the rural background, the Education Set up Religion

Characteristics Age groups (yrs) 18-25 25-35 35-45 Single Married Divorced Widowed Hindu Muslim Sikh/ Christian Urban Rural Illiterate Primary High School Intermediate Graduate Postgraduate Student Unemployed/ Housewife Business Private Job Govt. Job Positive Negative Positive Negative Dysfunctional Absent Poor in High in HARS HDRS PSLES

Marital status

subjects were from Hindu religion, while most of males were students, and the females were housewife. Psychological problems

were present in most of the subjects in both the groups. The scores on the Hamilton scale of anxiety
13 12

Male (n=20) No. % 16 80.0 2 10.0 2 10.0 10 50.0 8 40.0 --2 10.0 18 90.0 2 10.0 --16 80.0 4 20.0 --2 10.0 2 10.0 4 20.0 4 20.0 6 30.0 6 30.0 2 10.0 4 4 4 -20 2 18 18 -16 18 2 3 18 20.0 20.0 20.0 -100.0 10.0 90.0 90.0 -80.0 90.0 10.0 15.0 90.0

Female (n=20) No % 13 65.0 5 25.0 2 10.0 5 25.0 13 65.0 1 5.0 1 5.0 16 80.0 1 10.0 1 5.0 15 75.0 5 25.0 2 10.0 1 5.0 4 20.0 4 20.0 8 40.0 1 5.0 4 20.0 12 60.0 -3 3 1 2 18 2 18 16 18 13 5 1 20 -15.0 15.0 5.0 10.0 90.0 10.0 90.0 80.0 90.0 75.0 25.0 20.0 100.0

(HAM-A)

and

depression
14

Occupation

(HDRS) against

were higher in female subjects as subjects. The PSLES Past History Family History Family functioning Jointedness Communication Noise level Scores

male

revealed more events in females, the events were personal, undesirable and in 13% they were desirable in nature. In the males the stressors undesirable were lesser We and were of a

nature.

conducted

regression analysis to find out the order of significance of the stressors.

The life time, most important stressors were similar in both sexes, and it was related to financial matters. Immediate ( within one year) stressors differed in both the sexes ,it was concerning education in males and related to family in females, however, education was also a reason of concern in female subjects the order of stressors is shown in Table -2. Most of our subjects came from the rural background (85%).The family functioning gave similar result in both the groups, commonest dysfunction was in terms of disjointedness and noise level, female subjects showed significant familial gains.

Indian J. Prev. Soc. Med Vol. 42 No.3

233

July-September, 2011

Anuradha et al

A comparative study of psychosocial factors in male and female patients of conversion disorder

Table-2: Order of stressors in the two groups Stressors Immediate (last one year) Male 1. Studies, 2.Problem at work place, 3.Unemployment, 4. Sexual dissatisfaction, 5. Family dispute. 1. Financial matters, 2. Illness in the family, 3. Loan repayment, 4. Conflict with in-laws, 5. Marital conflict Female 1.Family issues, 2.Educational difficulty, 3.Relationship issues, 4.Marital conflict, 5.Spouse staying away 1. Financial issues, 2. Family dispute, 3. Conflict with in-laws, 4. Illness in the family, 5. Alcohol abuse by the spouse.

Life time

DISCUSSION
Our study shows that conversion disorder is prevalent in males and females; however, there are subtle differences in the two sections
15

.This disorder is precipitated by the presence of a significant stressor and at times maintained by an ongoing
16

stress. Stress is a cause of concern since a long time, though it has taken on new dimensions in the present times. Stressful events can take away the sense of control from an individual, leading to significant incapacitation and emotional distress .

Studies have shown a female preponderance in this disorder, we, however did not look into that aspect in our present study. The present study showed a higher number of married females suffering from this disorder in comparison to the male subjects; this finding is the same as in other studies
15, 17

The nature of stressors differed in both the sexes, in males it ranged from educational issues to familial issues and in females relationship issues were more important, this observation is the same as has been found in other studies
11, 18

. An

interesting observation emerged from our study that the lifetime stressors are the same in both sexes and it is related to financial matters, this finding becomes important when therapeutic interventions are undertaken as financial management should also be discussed while dealing with patients of this disorder, we could not find similar result in the literature to this effect. Scoring on PSLES showed a number of stressors which were of an undesirable nature these findings are expected as the reaction to stress is severe in events which are negative . Positive events like marriage or getting a job can become stressful as they require adjustments in the life style of individuals and in interaction with the significant others in the environment
19 17

. The regression analysis shows the order of significance of stressors in our study which shows that the

stressors are also determined by the age group; like sexual relationship is an important issue in younger age groups and financial issues are important in older age groups, some what similar results have been seen in one study although a different scale was used to assess the stressors .Lower socio economic status and rural population were found to have more conversion disorder, this can be attributed to the fact that issues of survival and hardships have to be dealt with on a daily basis and also that the coping mechanisms are not enough to solve these problems, other studies also support this finding Anxiety and depressive symptoms are usually present in these subjects
21 15 20

, but they are of a lower intensity and not

21

enough to fulfil the diagnostic criteria. In our study male and female subjects scored positive on the scales for anxiety and depression. Understandably these subjects benefit with treatment by anxiolytics and antidepressants . Looking at the

significance of associated findings of this study like age, sex, marital status, educational level and socioeconomic status in relation to contemporary studies we find that conversion disorder can occur at any age from childhood to old age, but it is most common in adolescents and young adults
17

Indian J. Prev. Soc. Med Vol. 42 No.3

234

July-September, 2011

Anuradha et al

A comparative study of psychosocial factors in male and female patients of conversion disorder

In an Indian study

22

, female subjects having conversion disorder were included and the authors reported that women

with conversion disorder were below the age of 35 but the subjects diagnosed with possession disorder were older. Subjects were poor, mostly illiterate, married, from a rural background, working and Hindus by religion. Most of the subjects had only one living parent and in cases where it was the father, he was found to be authoritarian and non-communicative, role models were also present in the subjects. Our study did not find this in the family history and none of our subjects had a diagnosis of possession disorder, hence it is difficult to compare the results. Life stressors in these women were found to be more than the comparative male subjects. Our study also found some what similar results, although we did not look into various aspects which the above study looked into. We looked in to the family functioning in both the groups and found significant dysfunction in terms of disjointedness, communication pattern, and noise level, this finding is corroborated by other studies in this area .One interesting observation emerged from our findings, that the female subjects had more positive gains from their symptoms e.g. getting respite from household chores, being near the spouse, being able to meet the parents etc., this particular aspect is important to emphasize to the subjects when therapy is undertaken and this point can help in understanding the maintaining factors.
23 19

We conclude that conversion disorder is a common problem , it occurs in lesser degree in males, married subjects are more vulnerable, lower socio economic status and rural background are important vulnerability factors, immediate stressors differ in both sexes but long term stressors are somewhat similar in both the sexes and are related to financial matters. Anxiety and depressive symptoms were also present in both the groups; family dysfunction was common in both the groups. There are a couple of limitations in this study, the sample size is too small to draw any meaningful conclusions, a comparison of the family functioning would have been helpful in understanding this problem further. The positive aspects of the present study is its focus on the male subjects as there is a lack of data on this section of the society and stress is a common feature in the present scenario.

REFERENCES
1. 2. 3. 4. 5. Kendell RE. A new look at hysteria. Medicine 1974; 30:1780-1783 Lewis A. The survival of hysteria. Psychological Medicine 1975; 5: 9-12 Veith I. In: Hysteria: The history of a disease. Chicago. University of Chicago Press. 1965:54 Mersky. Hysteria. British Journal of Psychiatry, 1986;149:23-28 Pu T, Muhammad E, Imam K, El-Roey AM. One hundred cases of hysteria in Eastern Libya: A socio-demographic study. British Journal of Psychiatry. 1986; 148:606-609 6. 7. Mace CJ. Hysterical Conversion. I: A history. British Journal of Psychiatry. 1992; 161: 369-377 DSM IV. (Diagnostic and Statistical Manual of Mental Disorders 4 Washington DC. 1994 8. Atkinson RL. Stress and Coping. In: An introduction to psychology. Harcourt Brace Jovanovich College Publishers. Fortworth. 1993: 576. 9. Gelder M. Anxiety, obsessive-compulsive and dissociative disorders. In: Oxford textbook of psychiatry. 3 University Press. 1996. pp 152 10. Fenton GW. Symptomatology of hysteria. Br. J. Psychiatry 1986; 149: 28-37.
rd th

edition). American Psychiatric Association,

ed. Oxford

Indian J. Prev. Soc. Med Vol. 42 No.3

235

July-September, 2011

Anuradha et al

A comparative study of psychosocial factors in male and female patients of conversion disorder

11. Aamir S. Stressful Life Events in the onset of Dissociative (Conversion) Disorders. J Pak Psych. Society 2005; 2(2),65 12. Hamilton M.The assessment of anxiety states by rating. Br J Psychiatry 1959; 32: 50-55. 13. Hamilton M .A rating scale for depression. J Neurol Neurosurgery Psychiatry.1960;23;56-62. 14. Singh G, Kaur D, Kaur H. Presumptive stressful life events scale( PSLES)-A new stressful events cale for use in India.Ind J psychiatry 1984;26(2):107-14. 15. Maqsood N, Akram B, Ali W. Patients with conversion disorder; Psycho-social stressors and life events. Professional Med J 2010;17(4):715-720. 16. Nizami A, Mariam H, Minhas FA, Najam N. Social Stressors In Patients with somatoform Disorders. J Pak Psych Society 2005; 2(1):20-3. 17. Mumford DB, Minhas FA, Akhtar I, Akhter S, Mubbashar MH. Stress and Psychiatric Disorders in Urban Rawalpindi. Community survey. Br J Psychiatry. 2000; 177:557-62. 18. Chaudhry HR, Arshad N, Niaz S, Cheema FA, Iqbal MM, Mufti KA. Fifteen-year follow -up of conversion disorder. International Psychiatry 2005; 2(10):17-9. 19. Irpati AS, Avasthi A, Sharan P. Study of stress and vulnerability in patients with somatoform and dissociative disorders in a psychiatric clinic in North India. Psychiatry Clin Neurosci 2006; 60(5):570-4. 20. Shikura R, Tashiro N. Frustration and fulfillment of needs in dissociative and conversion disorders. Psychiatry Clin Neurosci. 2002; 56(4):381-90. 21. Khan MN, Ahmad S, Arshad N, Ullah N, Maqsood N. Anxiety and depressive symptoms in patients with conversion disorder. J Coll Physicians surg Pak. 2005;15(8):489-92 22. Deka K, Chaudhry PK, Bora K, Kalita P.A study of clinical correlates and socio-demographic profile in conversion disorder. Ind J psychiatry.2007; 49(3):205-7. 23. David TC. Stressors in hysteria. Br J Psyhiatry.1989; 155:391-98.

----

Indian J. Prev. Soc. Med Vol. 42 No.3

236

July-September, 2011