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Psychiatric Comorbidity in Patients with

Conversion Disorder and Prevalence of
Dissociative Symptoms
a

Sinan Yayla MD , Bahadr Bakm MD , Onur Tankaya MD , Omer Akil

d

Ozer MD , Oguz Karamustafalioglu MD , Hulya Ertekin MD & Atilla

Tekin MD

Department of Psychiatry, Kastamonu State Hospital, Kastamonu,

Turkey
b

Psychiatry Clinic, Canakkale Onsekiz Mart University Medical

School, Canakkale, Turkey

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Department of Psychiatry, Samsun Mental Health Hospital, Samsun,

Turkey
d

Department of Psychiatry, Sisli Etfal Research and Teaching

Hospital, Istanbul, Turkey
e

Psychiatry Clinic, Istanbul Uskudar University, Istanbul, Turkey

Department of Psychiatry, Cizre State HospitalSirnak, Turkey

Accepted author version posted online: 03 Nov 2014.Published
online: 07 Jan 2015.

To cite this article: Sinan Yayla MD, Bahadr Bakm MD, Onur Tankaya MD, Omer Akil Ozer MD, Oguz
Karamustafalioglu MD, Hulya Ertekin MD & Atilla Tekin MD (2015) Psychiatric Comorbidity in Patients
with Conversion Disorder and Prevalence of Dissociative Symptoms, Journal of Trauma & Dissociation,
16:1, 29-38, DOI: 10.1080/15299732.2014.938214
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Journal of Trauma & Dissociation, 16:2938, 2015

Copyright Taylor & Francis Group, LLC
ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2014.938214

Psychiatric Comorbidity in Patients

with Conversion Disorder and Prevalence
of Dissociative Symptoms
SINAN YAYLA, MD
Downloaded by [Dr BAHADIR BAKIM] at 01:55 30 January 2015

Department of Psychiatry, Kastamonu State Hospital, Kastamonu, Turkey

BAHADIR BAKIM, MD
Psychiatry Clinic, Canakkale Onsekiz Mart University Medical School, Canakkale, Turkey

ONUR TANKAYA, MD
Department of Psychiatry, Samsun Mental Health Hospital, Samsun, Turkey

OMER AKIL OZER, MD

Department of Psychiatry, Sisli Etfal Research and Teaching Hospital, Istanbul, Turkey

OGUZ KARAMUSTAFALIOGLU, MD
Psychiatry Clinic, Istanbul Uskudar University, Istanbul, Turkey

HULYA ERTEKIN, MD
Psychiatry Clinic, Canakkale Onsekiz Mart University Medical School, Canakkale, Turkey

ATILLA TEKIN, MD
Department of Psychiatry, Cizre State Hospital, Sirnak, Turkey

The 1st objective of the current study was to investigate the

frequency and types of dissociative symptoms in patients with
conversion disorder (CD). The 2nd objective of the current
study was to determine psychiatric comorbidity in patients with
and without dissociative symptoms. A total of 54 consecutive
consenting patients primarily diagnosed with CD according to
Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision, criteria who were admitted to the psychiatric emergency outpatient clinic of Sisli Etfal Research and
Teaching Hospital (Istanbul, Turkey) were included in the study.
Received 4 December 2013; accepted 9 June 2014.
Address correspondence to Bahadr Bakm, MD, Psychiatry Clinic, Canakkale Onsekiz
Mart University Medical School, 17100, Canakkale, Turkey. E-mail: bbakim@yahoo.com

29

Downloaded by [Dr BAHADIR BAKIM] at 01:55 30 January 2015

30

S. Yayla et al.

The Structured Clinical Interview for DSMIV Axis I Disorders,

Structured Interview for DSMIV Dissociative Disorders, and
Dissociative Experiences Scale were administered. Study groups
consisted of 20 patients with a dissociative disorder and 34 patients
without a diagnosis of any dissociative disorder. A total of 37% of
patients with CD had any dissociative diagnosis. The prevalence
of dissociative disorders was as follows: 18.5% dissociative disorder not otherwise specified, 14.8% dissociative amnesia, and 3.7%
depersonalization disorder. Significant differences were found
between the study groups with respect to comorbidity of bipolar disorder, past hypomania, and current and past posttraumatic stress
disorder ( ps = .001, .028, .015, and .028, respectively). Overall
comorbidity of bipolar disorder was 27.8%. Psychiatric comorbidity
was higher and age at onset was earlier among dissociative patients
compared to patients without dissociative symptoms. The increased
psychiatric comorbidity and early onset of conversion disorder
found in patients with dissociative symptoms suggest that these
patients may have had a more severe form of conversion disorder.
KEYWORDS conversion
comorbidity

disorder,

dissociative

symptoms,

Conversion disorder (CD) is defined as the emergence and course of one or

more symptoms that are caused by psychological conflicts or needs affecting
the voluntary motor or perceptual functions. Although CD may develop at
any time between early childhood and late old age, it is reported to be
most common between 15 and 35 years of age (Chandrasekaran, Goswami,
Sivakumar, & Chitralekha, 1994). In Western societies the rate of CD is 1%
to 3% in outpatient psychiatry clinics, whereas in non-Western societies it is
about 10% (Tomasson, Kent, & Coryell, 1991). CD is more prevalent among
females compared to males, with a ratio between 2:1 and 10:1 (Hollifield,
2007). CD is also more prevalent in rural areas, in developing countries,
among people of low socioeconomic classes, among undereducated people,
and among those with relatively low medical knowledge (Nandi, Banerjee,
Nandi, & Nandi, 1992).
CD may be accompanied by a neurological or psychiatric disorder.
Comorbidities significantly affect the prognosis and the treatment of CD
symptoms. The most common psychiatric comorbidities for CD are mood
disorders, anxiety disorders, dissociative disorders (DDs), and somatoform
disorders. In a study by Bowman and Markand (1996), depressive disorders were reported to accompany CD at a rate of 88%. In another study
by Kuloglu, Atmaca, and Tezcan (2003), comorbidity rates for depression,
anxiety disorders, and DDs with CD were found to be 35.3%, 34.8% and

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Journal of Trauma & Dissociation, 16:2938, 2015

31

9.6%, respectively. Kaygisiz and Alkin (1999) reported that 83.6% of patients
with CD had at least one psychiatric comorbidity, and rates for depressive
disorders were reported to be between 34.3% and 50%. Personality disorders
also accompany CD. In a study focusing on patients with pseudoseizures,
the rates for borderline personality disorder, histrionic personality disorder,
and antisocial personality disorder were 55%, 16%, and 11%, respectively
(Rechlin, Loew, & Joraschky, 1997). Sar, Akyuz, Kundakci, Kiziltan, and
Dogan (2004) investigated the frequencies of psychiatric disorders with CD
and reported that 89.5% of patients with CD had at least one psychiatric
comorbidity. In the same study, the most common diagnoses were as follows:
undifferentiated somatoform disorder, generalized anxiety disorder, specific phobia, major depressive disorder, obsessive-compulsive disorder, and
dissociative disorder not otherwise specified (DD-NOS). Among inpatients
with CD, the prevalence of DDs was found to be 30.5%, and dissociative
identity disorder (DID) was the most common diagnosis (Tezcan et al., 2003).
In a study by Sar et al. (2004), the comorbidity of DDs with CD was reported
to be up to 47.4% in an outpatient clinical population. The comorbidity
of DDs may interfere with the treatment of the primary disorder, further
complicating the prognosis. Patients with CD usually present with acutely
occurring symptoms suggestive of an organic disease, which seems frightening to patients and to significant others, causing them to be admitted to
emergency units (Tobiano, Wang, McCausland, & Hammer, 2006).
In this study we aimed (a) to investigate the comorbidities of CD and
DDs among patients presenting with CD symptoms in the emergency unit of
a general teaching and research hospital in Turkey and (b) to compare those
patients with a DD with those without a DD in terms of disease severity and
past history of other psychiatric diagnoses.

METHOD
Participants
All patients who were admitted to the emergency unit of the Sisli Etfal
Research and Teaching Hospital in Istanbul, Turkey, over a 3-month period
(June 1 to August 31, 2011) and who had a clinical diagnosis of CD were
considered for participation in the follow-up study. Patients were evaluated medically in the emergency room by emergency physicians and then
were referred for psychiatric consultation. Psychiatric evaluation was performed by a senior psychiatrist in a separate room of the emergency unit.
A total of 54 patients were included in the study. Inclusion criteria were
as follows: (a) age between 18 and 65 years; (b) presence of CD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,
Text Revision, diagnostic criteria; and (c) ability to read and understand the
Turkish language.

32

S. Yayla et al.

Exclusion criteria were as follows: (a) presence or history of a neurological disorder; (b) lack of cognitive ability to maintain an interview; (c)
any current or past diagnosis of schizophrenia, other psychotic disorders, or
abuse of or dependency on alcohol or any other substance; and (d) presence of a serious medical condition (cancer, renal failure, diabetes mellitus,
cardiac failure, asthma, etc.).

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Measures
A sociodemographic form was produced to collect relevant data, including
age, sex, occupation, marital status, highest level of education, family history of psychiatric disorders, and duration of current illness. The Structured
Clinical Interview for DSMIV Axis I Disorders (SCID-I), Structured Interview
for DSMIV Dissociative Disorders (SCID-D), and Dissociative Experiences
Scale (DES) were used to confirm diagnosis and to evaluate dissociative
experiences.
SCID-I. The SCID-I is a structured clinical interview for DSMIV Axis I
disorders and contains six modules. The SCID-I evaluates 38 of the DSMIV
Axis I disorders with their diagnostic criteria and 10 of the DSMIV Axis
I disorders without diagnostic criteria. The SCID-I evaluates the diagnosis
as current or past. Although the questions may be of help, the examiner
does not consider them to be absolute and search for threshold for the yes
answers. The SCID-I was developed by First, Spitzer, Gibbon, and Williams
(1997), and reliability and validity for the Turkish language were investigated
(orapoglu, Aydemir, Yldz, Danac, & Kroglu, 1999).
SCID-D. The SCID-D investigates dissociative symptoms and disorders via a structured clinical interview. The SCID-D has two parts. The
first part, in which each question has a scoring system, covers six symptom domains (amnesia, depersonalization, derealization, identity confusion,
identity change, and secondary symptoms of identity disorder), and every
response is paired with a score. Insufficient information is not scored. The
second part serves as maintenance, covering nine symptom domains (identity
confusion, rapid mood changes, depersonalization, different names, internal
dialogues, child fragments, age regression and flashbacks, different person,
and possession). If no score was obtained in the first part, there is no need to
continue on to the second part. At the end of the interview, diagnosis is confirmed or a list of symptoms as well as a total score may be obtained. Similar
to the SCID-I, the questions may be of help, however the examiner does not
consider them to be absolute and search for threshold for the yes answers.
The SCID-D was developed by Steinberg (1994), and reliability and validity
for the Turkish language were investigated by Kundakc, Sar, Kzltan, and
Yargc (2014).
DES. The DES is a self-rated scale comprising 28 items that are scored
on a 0-to-100 scoring system. The means of these 28 item scores make up

Journal of Trauma & Dissociation, 16:2938, 2015

33

a total DES score. Higher scores are suggestive of a DD but do not indicate
an absolute diagnosis. The DES is used for the evaluation of the severity
of dissociative experiences or as a screening test (Carlson et al., 1993). The
reliability and validity of the DES for the Turkish language was investigated
by Sar, Yargc, and Tutkun (2000).

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Procedure
Patients were evaluated using the aforementioned scales after the procedure
and the aim of the study were explained in detail and written informed
consent was obtained. Deviations from the standard written informed consent process were fully explained. The study was approved by the Sisli Etfal
Research and Teaching Hospital ethics committee. All evaluations were performed in the psychiatric examination room in the emergency unit shortly
after the initial medical examination for emergency admittance.

Data Analysis
All statistical analyses were performed using SPSS for Windows Version 17.0.
Sociodemographic and diagnostic parameters were given in numerical and
percentage values. Numerical parameters were analyzed in means, medians,
and standard deviations, and categorical data were given in proportions.
Nominal and ordinal parameters were evaluated using the chi-square test.
All tests were two-tailed, with an alpha value set to <.05.

RESULTS
A total of 54 participants with CD were included in the study. Participants
were classified into two groups according to the presence of a SCID-D
diagnosis and then compared with regard to sociodemographic and clinical
features and DES total scores.
Of the 54 participants, 49 were female (90.7%). A total of 20 of the
participants were diagnosed with at least one DD (37.03% of the entire study
sample). None of the male participants were diagnosed with a DD. DD-NOS
was the most common diagnosis among the patients with a DD (18.52%,
n = 10), followed by dissociative amnesia (14.81%, n = 8) and dissociative
depersonalization disorder (1.08%, n = 2). No diagnosis of dissociative fugue
or DID was found (see Table 1). The mean total DES score was significantly
higher among the participants with a DD compared to those without a DD
(29.30 vs. 9.11, respectively, p < .001).
There were no differences between the groups in terms of age, years of
education, marital status, or employment status (see Table 2). However, there
were significant differences between the groups in terms of family history

34

S. Yayla et al.

TABLE 1 Distribution of Dissociative Disorders Among the Dissociative Disorder Group

Disorder

Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Depersonalization disorder
Dissociative disorder not otherwise specified

8
0
0
2
10

40
0
0
10
50

TABLE 2 Sociodemographic Features of the Study Groups

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Feature
Age in years, M SD
Sex, n (%)
Female
Male
Education in years, M SD
Marital status, n (%)
Single
Married
Divorced/widowed
Employment status, n (%)
Employed
Unemployed

DD (+)
(n = 20)

DD ()
(n = 34)

28.05 7.54

29.21 8.05

20 (100)
0 (0)
9.85 4.38

29 (85.3)
5 (14.7)
8.79 4.38

9 (45)
10 (50)
1 (5)

12 (35.3)
20 (58.8)
2 (5.9)

8 (40)
12 (60)

17 (50)
17 (50)

Notes: DD(+) = dissociative disorders group; DD() = no dissociative disorders group.

of psychiatric disorders, age at onset, duration of the disease, and current

comorbidities for bipolar disorder and posttraumatic stress disorder. None of
the participants in the group without a DD had a family history of psychotic
disorders, whereas three of the participants in the group with a DD had a
positive family history of psychotic disorders (p = .046). A positive family
history of anxiety disorders was more prevalent among the group with DD
compared to the group without DD (30.0% vs. 5.9%, respectively, p = .041).
No difference was found between the groups in terms of a positive family
history of mood disorders (45.0% vs. 29.4%, respectively, p = .24). Age at
onset of CD was significantly younger among the group with a DD compared
to the group without a DD (20.45 vs. 24.29 years, respectively, p = .02). Mean
duration of CD among the group with a DD was found to be significantly
longer than for those without a DD (7.60 vs. 4.97 years, respectively, p =
.03). Bipolar disorder was found to be more prevalent among the participants
with a DD compared to those without a DD (55% vs. 11.8, respectively, p =
.001). Current and past diagnoses of posttraumatic stress disorder were also
more prevalent among participants with a DD compared to those without
a DD (20.0% vs. 0% and 35.0% vs. 8.8%, respectively, ps = .015 and .028,
respectively; see Table 3).

Journal of Trauma & Dissociation, 16:2938, 2015

35

TABLE 3 Clinical Features of the Study Groups

Feature

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Family history of (%)

Psychotic disorders
Mood disorders
Anxiety disorders
Age at onset in years, M SD
Duration of disease in years, M SD
Prevalence of bipolar disorder (%)
Prevalence of PTSD (%)
Current
Past

DD (+)
(n = 20)

DD ()
(n = 34)

15.0
45.0
30.0
20.45 5.02
7.60 5.64
55

0
29.4
5.9
24.29 6.03
4.97 6.00
11.8

.046
.247
.041
.020
0.03
.001

20.0
35.0

0
8.8

.015
.028

Notes: DD(+) = dissociative disorders group; DD() = no dissociative disorders group; PTSD =
posttraumatic stress disorder.

DISCUSSION
CDs, DDs, and their comorbidities have been extensively investigated, but, to
the best of our knowledge, the comorbidity of the two has not been widely
investigated. CD is still a common clinical condition in Eastern countries, in
terms both of general medicine and of psychiatric care. We therefore aimed
to investigate the comorbidity of CD and DD as well as clinical characteristics of CD with and without DD. Nearly all prevalence studies of CD have
reported a female dominance in terms of female-to-male ratios for the prevalence of CD (Sar et al., 2004; Sar, Yargc, & Tutkun, 1996; Tezcan et al., 2003).
The current study had a female-to-male ratio of 9.8:1, and none of the male
participants had a diagnosis of DD.
Twenty of the participants were diagnosed with a DD (37.03% of the
study population). In a study by Tezcan et al. (2003), 30.5% of inpatients
with CD were found to have a comorbid DD diagnosis. In another study
by Sar et al. (2004), 47.4% of outpatients with CD were reported to have
a comorbid DD diagnosis. Our findings for the comorbidity rate of CD and
DD among patients admitting to an emergency department stand between
these two previously reported rates. In Sar et al.s (2004) follow-up study
patients were recruited from a tertiary outpatient psychiatric clinic of a
university hospital, and this may have accounted for the high comorbidity
rate found in that study, as comorbidity of DD is associated with more
severe cases of CD. In the current study, the most common DD diagnosis in
patients with CD was DD-NOS (with a rate of 50%), followed by dissociative
amnesia (with a rate of 40%). None of the participants were diagnosed with
DID. In a study of outpatients with CD, DD-NOS was reported in 34.2% of
the participants, whereas the rate of DID was 7.9% (Sar et al., 2004). In a
study of inpatients with CD, the comorbidity rate for DID was reported to
be 50%, whereas the comorbidity rate for DD-NOS was 44.5% (Tezcan et al.,

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36

S. Yayla et al.

2003). Depersonalization disorder was found in 10% of the DD group in the

current study.
A family history of psychotic disorders and anxiety disorders was significantly more common among the DD(+) group compared to the DD()
group. Overall, the rate of a positive family history of any psychiatric disorders was significantly higher in the DD(+) group compared to the DD()
group, which may suggest a higher psychopathological burden of family.
In a study by Deveci, Taskn, and Dinc (2007), the rate of a positive family
history of any psychiatric disorder was found to be 13.5% regardless of the
comorbidity of a DD. Because a negative family structure was associated
with higher levels of dissociation, the higher levels of family psychopathology may be related to higher levels of DD comorbidity seen in DD(+) group
(Nash, Hulsey, & Sexton, 1993).
The age at onset of CD was also found to be significantly earlier in
the DD(+) group compared to the DD() group. The mean age at onset
among the DD() group was 24.29 6.03 years in the current study,
whereas the mean age at onset in the DD(+) group was 20.45 5.0 years.
In a study by Gulseren, Ozmen, Onal, and Kultur (1993) evaluating outpatients with CD, the mean age at onset was reported to be 24.1 10 years.
It has been reported that the longer duration of the CD was associated with
the comorbidity of personality disorders as well as DDs, further worsening
the course of the disease (Wyllie, Friedman, & Luders, 1991). Our findings
indicating a more chronic course support the previous findings.
The rate of any psychiatric comorbidity was 87% for the whole study
population, which is in accordance with previous reports (Binzer, Anderson,
& Kullgren, 1997; Kaygisiz & Alkin, 1999; Sar et al., 2004). In two different
studies the mean number of comorbid psychiatric disorders in patients with
CD was reported to be 2.8 and 4.4 (Bowman & Markand, 1996; Sar et al.,
2004). We found a statistically significant difference between the DD(+) and
the DD() groups in terms of the mean number of comorbid psychiatric
disorders (3.80 vs. 2.17, respectively), suggestive of a more severe form of
CD. The rates for lifetime bipolar disorders and posttraumatic stress disorder
were significantly higher in the DD(+) group than the DD() group (55%
vs. 11.8% and 20.0% vs. 0%, respectively). In a previously published study,
the rate of bipolar disorders was reported to be 2% among patients with
pseudoseizures, whereas DD was accompanying 91% of the study population (Bowman & Markand, 1996). There are some reports that suggest that
pseudoseizure-type CD may be a different kind of CD, placing itself closely
on the dissociative edge of the spectrum of DDs (Ozcetin et al., 2009).
Overall our study is the first study to investigate the comorbidity of
CD and DD in an emergency psychiatric setting of a general secondary
care hospital. However, there are some limitations. Although the interviews
were performed using structured clinical guides, the family history taken was

Journal of Trauma & Dissociation, 16:2938, 2015

37

entirely dependent on the reports of the participants. Moreover, the unbalanced distribution of the gender groups in the study population may require
careful attention while generalizing the conclusions of both sexes, especially
the male sex. Large sample studies combining different treatment settings
(outpatient/inpatient settings, emergency psychiatric units, etc.) may provide
a better understanding of the disorders and their interacting relations.

ACKNOWLEDGMENTS

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This work was performed at the Sisli Etfal Research and Teaching Hospital
Psychiatry Clinic, Istanbul, Turkey.

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