Good Children Presenting with Conversion Disorder

Abstract

A B S T R A C T Current conceptualizations of conversion disorder in childhood draw from a range of theoretical perspectives. A large subset of children afflicted with conversion disorder has recurrently been described as 'good', 'helpful', 'compliant', 'highachieving' and 'conscientious'. Family characteristics noted in this group include high family expectations, inarticulate family relationships and hostility towards psychological explanations with an over-emphasis on medical aetiology. Physicians experience parental displeasure and anxiety in the form of demands for investigations and treatment, and feel pressure to comply with parental requests. Like physicians, good children with conversion disorder also feel compelled to satisfy their parents. As children, they are even less able to openly disagree with parental views or expectations, and manage their fear of parental rejection, hostility, anger or displeasure through compulsive compliance. This article discusses the contributions of attachment theory to our understanding of relationship patterns in families of extremely good compliant children and expands Taylor's concept of 'intolerable predicaments'. The development of the 'compulsive compliant' attachment strategy is discussed, and its application to the theory and treatment of children with conversion disorder is examined. Case vignettes are presented.K E Y W O R D S attachment theory, compulsive compliance, conversion disorder, predicament

The Developmental Origins of Conversion Disorders

“…The lasting nature of symptoms in this subset of individuals with conversion disorder may reflect recruitment of a phylogenetically older mechanism of managing threat and danger when phylogenetically more recent mechanisms (for example, resolution of difficulties by flight, fight, or verbal negotiation) have failed or been blocked (Porges, 2001). This phylogenetic explanation is consistent with two centuries of clinical observation, where conversion symptoms have been noted to be associated with strong emotions, intolerable relationship predicaments, or situations that threaten the individual's physical or psychological integrity (Carter, 1853;Craig, 2001;Janet, 1889;Kozlowska, 2001Kozlowska, , 2005Ludwig & Lexington, 1972;Roelofs & Spinhoven, 2007;Seltzer, 1985;Taylor, 1986).…”

“…Finally, this subgroup of patients appears to be analogous to the group of compliant, high-achieving children described in the conversion disorder literature (Kozlowska, 2001(Kozlowska, , 2003 and also to the group of adult patients with specific unexplained neurological deficits, where functional imaging shows dynamic changes at some level of the somatosensory neural network (Black, Seritan, Taber, & Hurley, 2004). It is also likely that the historical symptom of 'la belle indifference' (American Psychiatric Association [APA], 2000;Breuer & Freud, 1895) was coined and subsequently used by clinicians who treated this subset of conversion patients.…”

“…This subset of children appears to be analogous to the children with conversion disorder from families with 'chaotic social circumstances' (Kozlowska, 2001) who use illness behaviours to communicate discomforts or distress (Wilkinson, 1986(Wilkinson, , 1988; to the adult patients with psychogenic gait described by Morris et al (2005); and to patients with depression and comorbid disorders, where psychiatric and somatoform symptoms have been conceptualized as a form of appeasement display (Price et al, 2004). Finally, it is likely that patients who present with conversion disorder as part of a feigned helpless (Type C4/6) attachment strategy are a discrete subset of a large group of patients who, despite reasonable medical treatment and explanation, inappropriately perceive, evaluate, and act in relation to their state of health, a pattern referred to as 'abnormal illness behaviour' (Pilowsky, 1969).…”

Evaluation and Management of Psychogenic Nonepileptic Attacks

“…Attachment and social communication theories have been combined to explain conversion symptoms presenting in "good" children in the absence of the usual risk factors (e.g., abuse, overt stressors, family dysfunction) (Kozlowska, 2001 ). These children often do very well in school, are admired by peers, and generally lack recognizable psychopathology.…”

Functional Movement Disorders: Updated Overview

“…Irritability, depressive mood, and anxiety often coexist among these children [35]. Others become anorexic with considerable weight loss [36].…”