The Secondary Effects of Secondary Gains: A Case Report of Conversion Disorder - Juniper publishers
Journal of Trends in Technical and Scientific Research
Abstract
A partial or complete loss of the normal integration
between memories of the past, awareness of identity, immediate
sensations, and control of bodily movements is termed as dissociative
disorders, according to ICD-10. Initially called Hysteria, it was later
renamed as conversion disorder by Sigmund Freud, owing to the conversion
of psychological distress into physical symptoms. This disorder has a
higher prevalence in women and in lower socio-economic status. In this
case report, a psychoanalytic and behavioral model is used to explain
the dissociative convulsions. Other than the secondary gains that
usually accompany this disorder, the catharsis of anxiety has increased
chances of pregnancy.
Keywords: Conversion Disorder Somatization Pseudo-seizures Pregnancy Dissociative convulsions
Introduction
Conversion disorder, according to ICD 10, is a
dissociative disorder that involves partial or complete loss of the
normal integration between memories of the past, awareness of identity,
immediate sensations, and control of bodily movements. The diagnostic
criterion includes no evidence of physical or bodily impairment along
with evidence of a possible psychological stressor. Dissociative
Convulsions, or pseudo seizures may present a clinical picture of
movements, but tongue-biting, serious bruising due to falling, and
incontinence of urine are rare in dissociative convulsion, and loss of
consciousness is absent or replaced by a state of stupor or trance (WHO,
1984). Hippocrates was the first person to use the term ‘Hysteria’ to
describe these cluster of symptoms. He believed that it was caused
because of the movement of the uterus in the body, or the “wandering
uterus” [1]. The term conversion disorder was coined by Freud. He posits
that conversion disorder occurs due to somatization of the anxiety that
is present in the subconscious because of the conflicts within self
[2,3]. Conversion disorder was found to be higher in women and in young
adulthood from lower socioeconomic statuses [4]. In a general hospital,
20-25% of patients showed conversion symptoms and 5% met with the full
criteria [5]. Understandably this percentage increases in neurology
departments. Further, the prevalence is higher in women than men and up
to 31% in prevalent in third world countries [6].
The clinical picture of conversion may vary across
cultures. The most identifying features are both primary and secondary
gains in people with conversion disorder. The precipitating factor is
commonly easy to identify and has a temporalcorrelation with the onset
of the symptoms. The primary gain is explained through Psychodynamic
theory. According to Freud, a person’s Id, or the pleasure principle and
Super ego or the morality principle, are in a state of constant
conflict with each other. A stressor will exacerbate this conflict and
resulting in increased psychic anxiety. The ego, or the reality
principle, attempts to resolve this conflict based on the societal norms
and situations. Immature defenses suggest poor ego strength. Moreover,
unsuccessful resolution could result in anxiety that is somatized. In
this way there is a cathartic effect of conversion on the anxiety. The
secondary gain is more subtle in nature [2,6]. The learning theory
explains the secondary gain through reinforcement. The person, due to
their sickness is not only relieved from usual responsibilities and
decision making with respect to the stressful situation, but also
receives increased care and attention from their loved ones. This
becomes a reinforcer or a reward they receive for having these symptoms.
As a result of this, the probability of the symptoms recurring
increases [5,7].
Case Summary
Mrs. M was a 28-year-old married female from a low
socioeconomic status with complaints of episodes of fainting for the
past one and a half years and seizure-like attack for the past one year.
M was apparently normal till 1 and a half years back when she had an
episode of fainting when she and her husband were riding in a bike to
her hometown. She was going to visit her father in the afternoon and was
the pillion. She leaned on her husband and said she felt dizzy. Her
husband parked the bike alongside of the road. She had fainted bythen.
Around 30 seconds to one minute later, she regained
consciousness after her husband splashed her face with
water. She reported that she was stressed over the past few
weeks before the episode. She was facing a lot of criticism that
she was not able to conceive even after 1 and a half years of
marriage. Though she was undergoing treatment for the cysts
in her uterus, no one in her husband’s family was supportive of
her. They complained about her inability to conceive a baby and
called names to her on her face.
The second episode happened within the same month when
she fainted 2-3 times in the same day. Each time she would fall
or collapse for 4-5 seconds and then again consciousness with
normal levels of functioning. She was able to hear the people
around her calling out her name. There were no reported
instances of bruising or harming of self out of fainting. She was
consequently admitted in GH for 3 days. Her medical reports
indicated normal levels of brain activity; no abnormality was
detected. She was prescribed Tablet Diazepam which she
took for 2 weeks and then stopped as the episodes continued
to occur during the period of medication. 6 months after the
first episode, she began to have tonic-clonic seizure episodes
as well. These episodes occurred when she is alone or around
people. Since then M has had 3-4 episodes of seizure every
fortnight. Urinary incontinence, frothing or tongue-biting
were not present during the seizures. There was no report
of pre-ictal symptoms like aura, déjà vu, hallucinations etc.
Post-ictal symptoms like drowsiness, migraine, confusion
and disorientation were also absent. She reported increased
levels of care from her husband since episodes started.
Furthermore, M conceived 7 months after onset of episodes
and reported decline in frequency of episodes. M is currently
8 months pregnant. After pregnancy, the in-laws continue to
occasionally pass comment in front of the M that she is having
a child very late. She was referred from Institute of Obstetrics
and Gynaecology for diagnostic clarification owing to negative
finding in EEG, CT, MRI of the brain.
M was first born, delivered through normal vaginal delivery,
full term, normal birth weight. M’s mother committed suicide
3 months after her birth and M grew up with her maternal
grandparents, away from her father who was a farmer. There
were no significant physical illnesses or psychiatric illness.
She got married in 2014 when she was 23. She has a cordial
relationship with her husband. They were trying to get
pregnant since 2015 however they could not as there was a
cyst in her uterus. After some treatment, M conceived in July
2018. However, during the period in between M faced a lot
of stress due to the delay in pregnancy. The mother-in-law,
sisters and brother-in-law were critical about the scenario
and would pass comments in front of the M regarding the
same. After pregnancy, they continue to occasionally pass
comment in front of the M that she is having a child very late.
M was submissive and extremely adjustable in a relationship.
She doesn’t have many friends. She is shy, timid, sensitive but
emotionally controlled. She is quite and restrained.
Psychological test findings showed that her IQ of 91
indicates average level of performance intelligence. She got
scores indicative of moderate level of depression in Hamilton
Rating Scale for Depression. Significant conflicts in the area
of Self-concept with respect to lack of confidence and feelings
of worry, guilt related to her late conception, and conflicts
within laws were elicited in the Sentence completion test. She
also resents not being able to spend time with her father. In
the Thematic Apperception Test, her stories indicated that
the hero usually had feelings of self-doubt, helplessness,
anticipatory anxiety, uncertainty, insecurity. He was usually
submissive and indecisive in situations and showed elements
of loneliness. Needs of nurturance, secureness, Affiliation was
predominantly expressed and presses of poverty, rejection,
danger, aggression was seen. The environment was conceived to
be hostile, overpowering, uncertain and dangerous in the most
stories. The stories had largely a negative or uncertain ending
indicating M has a pessimistic view of the world. Defenses that
were employed principally were rationalization or acceptance.
This is suggestive of poor ego integration and strength. Though
M has needs that are unmet, the conception of environment as
overpowering and hero being help-less has led to a situation
where the needs are not expressed in majority of the stories. In
Rorschach Ink Blot Test, her responses suggested that M has high
need to differentiate perceptual experiences and has difficulty
in integration of reality. She prefers sticking to facts out of
fears of insecurity. A constrictive manner of interpretation
with little or no acknowledgement and expression of emotional
needs was seen. Content analysis shows disturbed adjustment,
stereotyped and narrow-minded view of the world as well as
marked levels of psychic anxiety as evidenced by high levels
of animal, nature and anatomical responses. The presence of a
seizure-like attack and rejection of a response- both in card 2
indicates strong emotional reaction to female genital organs;
emphasis on midline responses suggests she strives for
safety and security. M meets the Diagnostic criteria for F.44.5
Dissociative Convulsions according to ICD-10.
Case Formulation
The case will be formulated using the psychodynamic
and behavioral model. The patient’s mother died, 3 months
after her birth and she grew up with her grandparents. M did
not have a consistent primary caregiver as couldn’t spend
adequate time with her father. This inconsistence in a caregiver
is usually attached with insecure attachment style, features
of which can be seen in the Rorschach protocol. Insecure
attachment is usually associated with low self-esteem as can
be seen in M. It could also have been due her grandparents who
were authoritarian in parenting style. The warmth, support
and positive regard was not obtained, resulting in poor self concept. Furthermore, due to the poor economic condition
of the family, most of M’s needs were left unmet. Her id was
underdeveloped owing to this. Her super ego will be strong
from the values and morals that her grandparents imparted to
her through their strict norms and severe punishments when
mistakes were made. Ego of the patient did not fully develop
due to her strong super ego and poor self-concept, along with
her insecure feelings. She would often feel inadequate to make
decisions as a result of the poor self-esteem. Her poor ego
strength would lead to use of immature defense mechanisms
when intrapsychic conflicts arises as seen from her poor story
formation in TAT and employment of defenses for conflict
resolution in stories.
As an adult, after her marriage the delay in her pregnancy
exaggerated her feeling of low self-esteem and insecure
feelings. Living in a joint family with several relatives, M did
not have opportunity to spend quality time with her husband,
which could have increased her feeling of insecurity and did
not provide her necessary comfort. She thus continued to
have her anxiety levels increase. Her underdeveloped Id could
not express the need for his affection successfully as well.
These feelings were supressed by her super ego. At present,
the patient faces criticism from her in-laws directed towards
her physical self and abilities. Her low self-concept, and poor
Id development will prevent her from being assertive and
expressing her feelings. Instead, her super ego might dwell
on her in-law’s comments to induce increased levels of selfdoubt.
As a result of this, the anxiety builds up without being
resolved. The super ego repeatedly overpowered Id at the cost
of unresolved needs. These need induced anxiety eventually
surfaced to the consciousness in the form of somatization; in
the patient’s case, as a seizure-like attack or fainting episode.
The anxiety has been channelized in this method. This is the
primary gain obtained by the patient. After having released
the anxiety, the seizure-like attack had resulted in increasedcare towards her. This increased expression of love, warmth
and care she experiences fulfils her need of nurturance and
affiliation without requiring her to express the need directly.
This fulfilment serves a secondary reinforcement to her
behaviour, increasing the likelihood of another seizure-like
attack. She became pregnant after the onset of these symptoms
which led to increased care from her husband. There is a
reported decrease in the frequency and intensity of seizures to
support this formulation as well. In this manner she continues
to somatise her anxiety without proper conflict resolution, and
her secondary gain facilitated a secondary effect of pregnancy.
The ideal course of management would be to psycho-educate
her immediate family to reduce the secondary reinforcement or
increased care she is receiving due to her seizure-like attack.
The patient needs to be given psychotherapy focusing on her
assertiveness skills and coping techniques as a short-term goal
and resolution of intrapsychic conflicts on a long-term goal.
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