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Conversion Disorders

Chapter 15

CONVERSION DISORDERS

EDWIN A. WEINSTEIN, M.D.*

INTRODUCTION

HISTORY

The Civil War

After the Civil War

World War I

World War II

Korea and Vietnam

DEVELOPMENTS AFTER WORLD WAR II

Role of Violence

Denial

Dissociation

Organicity

Laterality

Epidemiology

DIFFERENTIAL DIAGNOSIS

Motor Disorders

Disorders of Stance, Gait and Balance

Involuntary Movements

Sensory Disorders

Visual Disorders

Hearing Loss

Speech Disorders

Pseudoseizures

Amnesia

Simulated Amnesia

Ganser Syndrome or Pseudodementia

TREATMENT

SUMMARY AND CONCLUSION

*Consultant in Neurology, National Naval Medical Center, Bethesda, Maryland; Consultant in Psychiatry, Walter Reed Army Medical Center,

Washington, D.C.; and Formerly Chief, Fifth Army Neuropsychiatric Center (World War II)
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384

Aaron Bohrod Tent Hospital 1943

Aaron Bohrod was engaged as an artist by the War Department Artist’s Advisory Committee and was in

the South Pacific, England, and France during World War II. In this painting, he captures the variety of

patients seen in a field hospital. Of particular interest is the patient in the wheelchair—slumped down, arms

completely limp, head back, vacant stare—a soldier who has seen too much and cannot even move himself

into an upright seated position. He presents as a classic conversion disorder with the obvious conflict

between his desire to serve and his invalidism which prevents it.

Art: Courtesy of US Center of Military History, Washington, DC.
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Conversion Disorders

INTRODUCTION

Although ideas of hysteria and conversion disorders have changed radically over the centuries,

almost all have emphasized emotional and physical

traumas and their effects on the brain or mind.

While the incidence of conversion reactions has

declined in developed countries, the occurrence of

the condition in association with violence and stress

makes it particularly relevant to military medicine.

Military approaches have been shaped by concepts

derived from civilian practice, and, in turn, wartime experiences have contributed greatly to current theoretical formulations. This chapter provides a historical review of conversion disorders in

wartime, considers epidemiological and demographic aspects, examines psychological, symbolic

and neural factors, and takes up problems of differential diagnosis and treatment.

A conversion disorder, as defined by the Diagnostic and Statistical Manual, 3rd edition, of the

American Psychiatric Association (DSM-III),1 is a

loss or alteration of physical functioning suggestive

of physical disease but expressing a psychological

conflict or need in a nonvoluntary fashion. In practice, the term is limited to findings on neurological

examination that imitate neurological disease, but

do not conform to anatomical or physiological patterns. It includes paralysis, somatic and special

sensory disturbances, involuntary movements,

pseudoseizures, speech, gait, and memory disorders, and excludes symptoms referable to the

gastrointestinal, cardiorespiratory, and genitourinary systems. Broadly, the symptom can be seen

as the symbolic representation of some problem

or disability. Conversion disorders are differentiated from hysterical personality, somatization

disorder, hypochondriasis, and psychogenic pain.

Pain, however, is commonly associated. The

terms conversion disorder and hysteria will be used

interchangeably here depending on contemporary

reference.

HISTORY

The Civil War

By the middle of the 19th century it had been

recognized that hysteria was a disease of the mind

and the brain, but it was still considered a female

malady. The gender difference was variously attributed to reflex irritation from the uterus and

ovary, to women’s greater sensitivity, emotionality, and impressionability, which made them more

sensitive to the effects of fear, excitement, grief and

jealousy, and to sexual repressions and frustrations. Both abstinence and overindulgence were

invoked as causes. Hysteria was known in men, but

only in those who were effeminate or homosexual.

Authors also emphasized heredity, citing mental

illness and diseases such as epilepsy and syphilis.

Against this background, it is not surprising that

cases of hysteria were not recorded in the Civil War,

in which the major neuropsychiatric disabilities

were nostalgia, soldier’s heart, and insanity. A

review, however, of individual cases in the medical

journals of the day suggests that a considerable

number of the 28.3% of discharges for epilepsy, and

of the 20.8% for paralysis involved conversion disorders.2 One such case was that of a 28-year-old

recruit who, after an altercation with an officer

while seeking to desert, became unable to move any

of his limbs. Subsequently, he developed violent

tremors of his head and upper extremities. Pressure

on the soles of his feet produced saltatory arching of

his back. On attempting to walk he would take a

few powerful and ungoverned steps and then throw

himself on a bed. He was discharged from service

with a diagnosis of choreic convulsion, and, 2 months

later was reported to be completely recovered.3

Further evidence for the existence of conversion

disorders in the Civil War comes from the records of

the military hospital set up at Turner’s Lane in

Philadelphia by William A. Hammond, SurgeonGeneral of the Union Army, for the study and treatment of wounds and other injuries of the nervous

system. There, Silas Weir Mitchell and his colleagues, George D. Morehouse and William W.

Keen,4 described seven cases of “reflex paralysis”

which were almost certainly conversion reactions.

In these patients a missile wound of an extremity

which had not damaged a major nerve resulted in a

transient paralysis of all four limbs or an enduring

weakness and sensory loss in several extremities.

In one instance, a man who had been shot through

the right thigh developed a loss of sensation over

the entire right half of his body. Patients responded
War Psychiatry

386

to faradic stimulation but only up to a point short of

complete recovery. Mitchell had studied in Paris,

then the leading center of neurology in the world,

and was familiar with the manifestations of hysteria. He may have considered the diagnosis as he

mentioned the case of an officer in the Mexican War

who had become “almost hysterical” after having

been shot through the heel. The officer, however,

had a reputation for courage under fire and it was

an article of faith that hysteria did not occur in

strong men not weakened by indulgence in sex,

alcohol, or tobacco.4

After the Civil War

The decades following the Civil War may be

regarded as the golden age of hysteria. The condition was romanticized in Victorian novels, and provided the central theme for the concepts of mental

illness put forward by Paul Briquet, Jean-Martin

Charcot, Pierre Janet, and Sigmund Freud.

Briquet5 found that hysteria occurred predominantly in lower-class women who led lives of hardships and poverty, rather than among the privileged groups of society. Taking up the role of

sexuality, he compared the incidence of hysteria—

as diagnosed by the standards of the time—in chaste

nuns, female domestic servants (who might supplement their incomes through sexual accommodations), and professional Parisian prostitutes. He

discovered the highest rate in prostitutes and the

lowest in nuns, with servants in between. Briquet

concluded that the significant agent was not sexual

indulgence per se but the distressing conditions

under which the activity was carried out. He thought

that emotions such as fear and grief affected the

part of the brain which was the seat of feelings and

that this in turn produced the hysterical symptom.

Jean-Martin Charcot6 believed that a past psychological trauma could affect the function of the

cerebral cortex, and produce such hysterical disorders as aphonia, hemiplegia, and seizures. He

showed that symptoms could be both produced and

removed by suggestion, and regarded susceptibility to suggestion and hypnosis as evidence of hereditary weakness of the nervous system. Charcot

thought that a volitional element might be present

and emphasized the need for discipline in treatment. He urged that patients be isolated from their

families and from others with hysteria to provide a

better moral environment. Charcot and his followers, known as the school of La Salpetriere, stressed

the so-called stigmata of hysteria, such as ovarian

tenderness, pharyngeal and corneal anesthesia, and

concentric constriction of the visual fields. Joseph

Babinski, one of Charcot’s pupils, believed that

hysterical hemianesthesias, and other manifestations were artifacts of the neurological examination produced by unconscious suggestion by the

physician.

Pierre Janet,7 another of Charcot’s disciples, believed that the traumatic event occurred in a setting

of altered consciousness or trance state, and was

not integrated into conscious awareness. The dissociated ideas and affects produced the hysterical

symptoms. Janet thought that chronic disease, organic affections of the nervous system, psychic

weakness, and a succession of cumulative emotional effects made the individual more vulnerable

to dissociation.

John Russell Reynolds8 in London proposed that

a hysterical paralysis was caused by the idea of a

paralysis and the emotion associated with it and by

a loss of the will to move the limb(s), and that

treatment depended on the removal of that idea.

Reynolds noted that in men the hysterical manifestations frequently came on after a fall from a horse

or other accident, and that in women idleness, preoccupation with domestic matters, and frigidity

were the principal factors. He also remarked on the

association with organic brain disease and physical

illness.

Joseph Breuer and Sigmund Freud9 in 1895 cited

such emotional traumas as guilt over a father’s

illness, unrequited love, and remorse over the wish

to marry a dying sister’s husband. They found that

hysterical symptoms brought on by even minor

upsets or injuries could be traced back to traumas

early in life for which the memory and associated

affect had been repressed. After Freud gave up the

seduction theory—the idea that the origin of hysteria lay in the sexual abuse of children—he held that

the original trauma involved emotions connected

with the child’s own sexual and aggressive drives.

These affects and memories were converted into

somatic symptoms in order to maintain a constant

level of energy in the nervous system. The hysterical manifestation, in Freud’s view, was the expression of sexual gratification along with efforts to

suppress it, although he agreed that nonsexual impulses might be involved.9 He later was to attribute

the traumatic neurosis of World War I to the narcissistic attachment of the libido to the ego, engendered not only by fear of battle but by reactivation

of the castration complex. Freud, like others, believed in a hereditary factor, noting that one half of

his patients with hysteria and psychasthenia (ie,

obsessions and phobias) had a syphilitic father.
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Conversion Disorders

Briquet, Charcot, and Freud had all described

hysteria in female patients. It was, however, not

until the rapid industrial growth following the Civil

War, particularly the expansion of the railroads and

the advent of compensation legislation and litigation, that the existence of male hysteria in the form

of the traumatic neurosis was generally recognized.

A man who had been shaken up or bruised in a

fall or a railway accident would complain of pain

and inability to move his legs, and examination

would show tenderness over the spine, and apparent paralysis and anesthesia below the waist. At

first these findings were attributed to injury of the

spinal column, or to concussion or anemia of the

spinal cord, but the observations of Herbert Page,

surgeon to the London and Northwest Railway, and

James J. Putnam of Boston established the functional nature of the condition. By 1895, James

Hendrie Lloyd, writing in Francis X. Dercum’s authoritative textbook on nervous disease, could state

that next to heredity, trauma was the most important cause of hysteria and that some of the worst

cases occurred in men. Others thought that patients

with railway spine were malingerers and, like Weir

Mitchell, did not accept the existence of male hysteria until World War I.

World War I

Conversion disorders, along with neurasthenia

(ie, anxiety and exhaustion), were the leading categories of neuropsychiatric breakdown in both combat and noncombat situations in World War I. There

were 6,250 cases, representing an incidence of 1.53/

1,000/y of total strength, admitted to U.S. military

hospitals from 1 April 1917 to 31 December 1918.10

Although Congress declared war in April 1917, it

was more than a year before U.S. troops engaged in

significant combat, and the data are derived mainly

from British, French, and German sources.

In the early years of the war, ideas of hereditary

and acquired predisposition to the effects of shell

shock provided explanations of conversion disorder and neurasthenia. Frederic W. Mott, a British

medical officer in charge of a large hospital in London, was the leading advocate of the view that the

concussive action of the shell explosions caused

minute brain hemorrhages, and that the large majority of men who broke down after such an experience had inborn neuropathic or psychopathic tendencies, a family history of alcoholism, insanity, or

epilepsy, or a timorous disposition.11,12 The French

differentiated the contusional effects of shell explosions with focal neurological signs and bloody or

xanthochromic spinal fluid, from the commotional

or concussional effects, and from the emotional

sequelae.

It was soon evident that conversion reactions

occurred in men who had not been in the immediate

proximity of an exploding shell. They appeared in

soldiers who had undergone terrifying and lifethreatening experiences, such as witnessing scenes

of death and mutilation or undergoing torpedoing

at sea. They were more apt to appear in places of

relative security before the opening of a barrage, or

after a man had reached a clearing station rather

than in the midst of combat. Conversion reactions

also occurred after relatively minor trauma—a slight

wound, bruises, or burns. It was not uncommon for

the conversion symptom to come on days, weeks, or

even months after the reported trauma, after what

Charcot had referred to as a phase de meditation.

There was a very low incidence of traumatic neurosis in prisoners of war.13

British, French, and German observers noted that

conversion reactions were more common at base

installations than in forward or combat support

areas. Eder14 found that 77% of patients at a British

hospital in Malta were so classified. U.S. experience

was similar in that there was a higher rate of hospital admissions for conversion disorders in men who

had never left the continental United States than in

those who had served overseas.10 Among patients

in General Hospital No. 3 set up in Plattsburg, New

York for the treatment of war neuroses, conversion

disorders outnumbered other categories combined.

The significance of preexisting constitutional factors was a controversial issue in the German as well

as the Allied armies. At the German Neurological

Congress held in Munich in September 1916, R.

Gaupp presented the case for predisposition, while

M. Nonne was the leading advocate of the view that

the cause of the war neuroses lay less in the personal

constitution than in the nature of the trauma. Working in hospitals in Hamburg and Schleswig Holstein, Nonne found that the “hysterical character”

was lacking in the majority of his cases.15 Hurst16

found many cases of gross hysterical symptoms in

British soldiers who had no family or personal

history of neurosis and who were perfectly fit up to

the time of the traumatic incident. It should be

noted that the original British Army in France was

made up largely of volunteers. Even Mott stated

later in the war that premorbid factors were important only in neurasthenia.11 Rather than occurring

in men with timorous dispositions, many conversion disorders were observed in noncommissioned

officers and enlisted men with good combat records,
War Psychiatry

388

and in daredevil types who had volunteered for

hazardous assignments such as dispatch rider,

stretcher bearer, or sniper.

Both British and American data indicated a

marked difference in the incidence of conversion

disorders in commissioned officers and enlisted

men. The British found that the symptoms displayed by officers were predominantly of the neurasthenic type, while enlisted men had mainly hysterical manifestations. In the British Army, rank

was an indicator of social class, and it was believed

that the forces of education, tradition, and example

in the officer groups made for greater self-control

and better ability to resist a sudden breaking emotion or trauma.17 In the U.S. Army, disability discharges for hysteria in officers were four times less

frequent than those for neurasthenia, whereas in

enlisted personnel the ratio was approximately

equal.10

Conversion symptoms included mutism and

stammering, deafness, gross tremor and other involuntary movements, paralysis and anesthesia,

abnormal postures and contractures, astasia (an

inability to maintain stance), abasia (an inability to

coordinate movements in walking), and other gait

disturbances, seizures, amnesia, and fugue states.

In the French Army paraplegia and monoplegia

were the most frequent forms of paralysis.18 Blindness was less common than blurring of vision

and blepharospasm. It was usual for soldiers to

report having been blown up or buried after a

shell explosion, and then having no memory of

events prior to arriving at the clearing station. There

were episodes of excitement and delirium for which

the soldier would later be amnesic, and periods of

stupor often preceded muteness, deafness, and

paralysis. The type and location of the conversion

manifestation was frequently determined by

the character of the trauma. Astasia-abasia,

the most common conversion manifestation of the

war, occurred frequently in men who had been

thrown violently to the ground and who had rolled

into a trench or hollow and had been able to get

to an aid station by laboriously walking or crawling.18 Hemiparesis might be preceded by an injury

to that side of the body. Paralysis or contracture of

a limb might follow a local wound, or might come

on after a period of immobilization in a splint, sling,

or cast.

A large number of cases, sometimes in epidemic

proportions, followed gas attacks. Chlorine and

mustard gas caused conjunctivitis making it painful for the man to close his lids, produced irritation

of the throat, larynx, and bronchial tree, and resulted in gastritis from swallowed saliva. These

symptoms usually cleared within 2 to 3 weeks, but

some soldiers developed hysterical blindness, ptosis,

aphonia, vomiting, and respiratory difficulty. (Adolf

Hitler became blind and mute for several weeks

after having been exposed to mustard gas in the last

days of the war, and may well have had a hysterical

disorder.) Gas neurosis epidemics also occurred

after desultory gas shelling or even after an alarm

had been erroneously sounded, even without evidence of inhalation or vesicant action.

Problems in diagnosis arose. Prior to the war

most physicians who had been engaged in private

practice or administrative work were not familiar

with the traumatic neuroses. Early in the war,

cases of conversion disorder were considered to

have organic disease and were evacuated to the

neurological centers in base areas where they

might be treated with rest, hydrotherapy, and other

measures which perpetuated the symptoms. It was

also shown that patients with evidence of brain

damage could have conversion manifestations.16,19

Moreover, such stigmata as hysterogenic zones

(ie, areas of anesthesia or tenderness on the back

or abdomen, concentric constriction of the visual

fields, and corneal and pharyngeal anesthesia)

proved to be unreliable indicators.15,16 As Babinski

had found, narrowing and spiraling of the visual

fields were frequently an artifact of the examination

of the perimeter of men who had no visual symptoms. Similarly the classical la belle indifference

(being indifferent to the situation) might not be

present.

Treatment included suggestion, persuasion, explanation, reeducation, hypnosis, and more physical measures such as isolation and deprivation,

faradization (stimulation by electrical current), and

sedation. Hypnosis was used with suggestion, and

also in attempts to recover repressed feelings and

memories. Psychotherapy strove to encourage catharsis, and deal with feelings of grief, shame, fear,

anger, and guilt. The overall experience was that

the efficacy of whatever treatment was employed

increased with proximity to the front and the

promptness with which it was applied. While hysterical manifestations might be removed at a base

hospital, the majority of such cases did not return to

successful combat duty. The soldier might develop

headaches and other manifestations of anxiety or

depression, or his conversion symptom might return during some frightening situation, such as a

London air-raid.17,19 The British found that amne-
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Conversion Disorders

sia, mutism, and paralysis responded readily as did

gas hysteria, while deafness was the most intractable.20 The American experience was that symptoms which occurred in conditions in which there

had been a definite trauma or acute emotional insult succeeded by a stage of amnesia or dissociation

had the best outcome.10

The French, in the tradition of Charcot and

Babinski, regarded conversion disorders not as diseases but as failures of will or attitude. Conditions

such as mutism, trembling, and paralysis were

treated first by persuasion and encouragement, and

if these measures were inadequate, by isolation and

bed rest without permission to read, write, or smoke.

If cure still had not resulted, painful faradic stimulation, torpillage (torpille = torpedo [numb fish]) was

applied. Inveterate hysterics were regarded as malingerers and might be subject to court-martial.18

The French were the first to treat such “emotional”

cases in forward areas, a policy not adopted in the

British Army until the winter of 1916 to 1917.

There were also cases in which conversion symptoms cleared after some emotional shock as in

the instance of a man with hysterical blindness

following torpedoing whose sight returned after

he was thrown into the sea. Another man suddenly regained speech during a bombing raid by

Zeppelins.17

The observations of conversion disorders in

World War I can be summarized as follows:

1. The conversion symptom was often a reenactment or symbolic representation of recent traumatic experience.

2. Trauma was a necessary but not sufficient

agent in that the incidence did not depend

on the severity of the injury or emotional

insult.

3. Symptoms might come on at a considerable

interval following trauma and persist in

chronic form.

4. Social class and education were significant

factors in that the incidence was greater in

enlisted men than in commissioned officers.

5. Individual predisposition was not a factor

in the sense that men who developed conversion disorders had had more mental illness or were of a more timid, nervous temperament.

6. Many forms of therapy were effective provided that they were administered promptly

and in close proximity to the soldier’s unit.

World War II

There was little academic interest in conversion

disorders in the decades following World War I.

The condition was thought to be disappearing because of greater sophistication and sexual liberation—actually a decline in incidence and less dramatic presentation had been noted at the turn of the

century—but other factors were involved. Nineteenth century physicians had focused on the physical stigmata of mental illness, whereas later ones

were more concerned with psychological mechanisms. New neurological procedures such as the

introduction of the Babinski sign and the delineation of the functions of the parietal lobe led to better

diagnosis. A number of the manifestations of conversion disorders were placed in the growing category of psychosomatic disease. Patients with conversion symptoms, who tended to be less educated

and more apt to come from rural areas, were not

considered good candidates for psychoanalytically

oriented therapy, and were likely to be treated by

local practitioners or referred to public clinics.21,22

Compensation traumatic neuroses were not considered worthy of scientific study.

Theoretical formulations, despite the experience

of the war, were for the most part reiterations

of Freudian concepts. These emphasized intrapsychic struggle and regression to earlier stages of

psychosexual development. Little attention was

given to current trauma which was regarded mainly

as a trigger of hitherto repressed drives and

conflicts. Hypnosis fell into disuse, as it was felt

that symptom removal did not touch the deeper

problems. It was also believed that conversion

symptoms might serve as a defense against a psychosis.23 Nonanalytically oriented psychiatrists saw

the issue as a conflict between the instinct of selfpreservation and the demands of society without

regard for situational factors and group interactive

processes.

Conversion disorders were much less common

in World War II than they had been in World War I,

but they made up a significant proportion of

neuropsychiatric casualties. Comparisons are difficult because revision of nomenclature had removed

the somatic manifestations of anxiety and cardiorespiratory, gastrointestinal, and genitourinary

symptoms from the conversion reactions. The rates

as a consequence of combat varied with the intensity of the fighting, the location and expertise of the

medical facility, and the conditions of evacuation.

Reports from combat support areas in Italy24 and
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390

Normandy and Germany25,26 showed an incidence

of about 5% of neuropsychiatric casualties. The

incidence among men evacuated to one hospital in

the South Pacific 4 to 6 weeks after the onset of

symptoms was 17%.27 A British report of neuropsychiatric casualties admitted to a rear-area installation during the retreat to El Alamein and the advance into Tripolitania gave an incidence of 26%.28

After a study of documents and interviews with

former Wehrmacht psychiatrists, Schneider29 concluded that conversion manifestations such as trembling and paralysis were common in the German

Army.

The conversion manifestations matched those of

World War I with paralysis of limbs, bizarre postures and gaits, involuntary movements and seizures, muteness and stammering, hearing and visual loss, and amnesia. There were also the stupors

and other acute dissociative reactions, referred to as

pseudopsychoses in which men experienced episodes of agitation, hallucinations and paranoid ideation, and performed such stereotypic activities as

digging foxholes with their fingers, and taking shelter under cots at any sudden sound. These reactions

occurred predominantly in young soldiers new to

their units. Swank,26 on the basis of his experience

in Normandy and Germany, noted that hysterical

paralyses and anesthesias occurred more frequently

in airborne troops with good combat records than

in other U.S. Army personnel and that the manifestations were almost always superimposed on a

wound, injury, or surgical procedure. Swank found

that all of his cases showed emotional tension rather

than the traditional la belle indifference.

Symptoms were also occupationally determined.

Anderson30 noted that airmen developed complaints

which did not totally incapacitate them, but which

did not allow them to carry out certain types of

operations. The symptoms included reduced visual acuity, impaired depth perception, diminished

night vision, and altered hearing. These caused

minimal discomfort, but disqualified the man from

formation and night flying and from use of the

intercommunication system. In many instances

flyers could hear everything perfectly well with the

sole exception of the radio beam. Blindness and

concentric visual field constrictions were rare. The

disability might be stated in terms of performance

rather than symptoms as a patient might complain

of difficulties in gauging distances when flying in

formation.31 Similarly, hysterical amblyopia was

observed to appear suddenly in soldiers in whom

the eye was particularly important in fighting, such

as sharpshooters.32 The following is an account of

an acute combat conversion reaction.

Case Study 1: One More Shot

A 23-year-old infantry staff sergeant was admitted on

a litter to the 601st Clearing Company in June 1944 during

the fighting about Grossetto, Italy. His right arm was

paralyzed below the elbow with a corresponding anesthesia. He stammered and said he could not see objects on

his left side, and could not recall the first three digits of his

serial number. He could recall nothing since being blown up

and buried in a shell explosion. He expressed great fear that

he would be killed. After examination which did not show a

hemianopia or organic weakness or sensory loss, and

assurances that he would recover, he was placed in

isolation. When interviewed 8 hours later he was markedly improved. He could move his arm, talk clearly, and

walk without assistance. He told the following story.

“First day of battle I shot a dago eight times because he

shot at me. I guess I must have just lost my head. We dug

in and went to bed. I was with the Armd. Div. [Armored

Division] riding tanks—three of my men got killed by shells

then just this side of Rome. We took Grossetto—took a

hill, man hit me with a rifle butt [scar in left supraorbit] that

scared me—I killed him with a bayonet—that bothered

me, my father taught me never to kill—he’s an invalid; he’s

a Christian man too....[W]alked some more, kept going

north into the mountains. Got pinned down, shelled for 2

hours, killed two of my men and a lieutenant. Got to a little

town; Battalion Commander lost his head, ordered four

men in; he got nicked then ordered us to withdraw. Then

went on tanks that shelled us [weeps], killed my lieutenant

...[m]y platoon leader was hit, I was in charge. I ordered my

men out. I stopped to take one more shot. I heard the

Germans holler FIRE in English and that’s all I remember

until they picked me up in a jeep. My gas mask and shoulder

straps had been shot off. Then I went to sleep and don’t

remember anything until this morning. The gun was blown

out of my hand, all that was left was the trigger part. I guess

the flash must have blinded me.”24(p135)

Comment: The case illustrates a number of features:

1. The manner in which the symptom is a condensed symbolic representation of current experience rather than a revival of some childhood conflict.

2. The relationship of the site of the conversion

manifestation to the type of physical injury.

3. The amnesia in which soldiers commonly reported that they remembered nothing from the

time they were “blown up” in a shell explosion

and “buried.” As noted in World War I, actual

burial incidents were infrequent although soldiers might be covered with debris. Rather the

“burial” symbolized fear and feelings about death.

4. The coincidental occurrence of recovery and a

dramatic account of traumatic experience.
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Conversion Disorders

5. The association of a conversion reaction with a

high degree of anxiety.

As in this patient, some men with conversion

reactions responded to suggestion and a period of

sleep and isolation. In others hypnosis and the

techniques of narcoanalysis33 or narcosynthesis34

were used. Each aimed at restoring the memory of

the combat experience and allowing the ventilation

of the affect. If the patient was amnesic it was

suggested after the injection intravenously of sodium pentothol or Sodium Amytal that he go over

the events immediately preceding the period for

which he had no recall. If there was no amnesia he

was asked to revisualize the scene just prior to the

onset of his symptoms.

The recall or revisualization was usually associated with marked emotion and excitement. Events

would be reenacted vividly: patients would yell,

cower in fear, or strike at an examiner who was

apparently mistaken for an enemy or a hated officer. In the method of narcosynthesis described by

Grinker and Spiegel the examiner would simulate

the sounds of combat, mimicking the antiaircraft

fire and the shouts of the bomber crew. Or if it was

known that the soldier was in a tank unit he would

be warned that his tank was on fire and he had to

climb out. Even though the patient might recall

events for which he had been amnesic, the therapeutic effects seemed to depend on the degree of

emotion displayed.

It was noted that patients might abreact with

the introduction of the drug even though no suggestion that he recall the trauma was made. Also,

the events that were reproduced were not necessarily those that preceded the onset of amnesia or other

conversion manifestations. Recollections might

be highly melodramatic with a mixture of fact

and fantasy.24,35,36 In a case treated by the author

at the U.S. Army’s 601st Clearing Company in

Italy, the patient who had become dramatically

blind “recalled” how he had been searching for his

brother among the dead and wounded. He later

admitted that his actual brother was safe in the

United States.

As in World War I, once patients had been

evacuated from their units, removal of a major

conversion symptom by any method did not

in most instances result in a successful return

to combat duty even though in some cases

soldiers asked to go back. It did, however,

diminish the need for further hospitalization,

and the majority of such soldiers could be released

for noncombat service. By the end of the Italian

campaign, the use of barbiturates at the U.S. Army

level had been reduced. If symptoms persisted,

despite attempts at abreaction, the patient

was placed in an isolation tent with minimal privileges and told when his nervous condition cleared

up he would be assigned to less hazardous duty. If

these measures failed, the man was evacuated to a

base section installation, where electroconvulsive

treatment was effective in treating amnesias,

mutism, seizures, astasia-abasias, deafness, and

hyperkinesias.37

The experience of the Holocaust emphasizes the

importance of motivation and secondary gain. Despite the terror, the gruesome conditions, and the

appalling amount of physical injury, conversion

reactions in the concentration camps were almost

unknown. Eitinger, a Norwegian psychiatrist, who

was a prisoner himself, commented on their rarity

in Auschwitz where the appearance of a symptom

meant instant death.38 Kral39 noted a few cases in

Terezin that occurred while prisoners were awaiting transportation to extermination camps further

eastward. Later studies of survivors showed a high

incidence of brain damage and post-traumatic stress

disorder.40

Korea and Vietnam

Rates of conversion disorders along with those

for other psychiatric casualties were lower in Korea

and Vietnam than they had been in World War II. In

Vietnam, character and behavior disorders and substance abuse predominated, and the incidence of

conversion reactions appeared to vary with proximity to combat. Jones,41 who served with an infantry division and field hospital in Vietnam, remarked

on the rarity of both combat fatigue and conversion

reactions, while a higher rate was suggested by

Carden and Schramel42 who saw their 12 patients

after they had been evacuated to the Philippines. In

a temporal frame, while the overall combat casualty

rate reached its peak in 1968 and 1969, the incidence

of conversion disorders continued to increase, reaching a 1975 high of 95/100,000/y in patients in U.S.

Army medical facilities worldwide, followed by a

steady decline.43

A prior wound was an important risk factor both

for conversion reactions and other psychiatric disorders among U.S. Marines.44 In U.S. Army personnel, Jones noted, similarly, that conversion manifestations were apt to appear when a wounded hospitalized

soldier was about to return to duty.
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DEVELOPMENTS AFTER WORLD WAR II

Whereas the combat experience of World War I

had little impact on psychiatric thought, that of

World War II profoundly affected developments in

areas relevant to conversion disorders. These concerned the:

1. Psychological and physiological effects of

stress and violence associated with traumatic life events in persons without prior

personality disorders or unusual emotional

problems. These include assaults and injuries, rape, medical and surgical illnesses,

natural catastrophes, political terrorism,

family violence, and death of a loved one.

2. Concept of denial as a coping mechanism

during and following trauma. Prior to the

war and the Holocaust, psychoanalysis had

focused on the denial or repression of unacceptable inner drives. Denial of external

reality was considered to be indicative of

severe psychopathology or a weak ego.

The war experience showed that denial

could be used by normal persons in adaptive—or maladaptive—fashion. The soldier who was well-integrated into his unit

perceived the hostile environment as less

life-threatening than the man who had little

confidence in his leaders, and was otherwise not identified with the values of his

group. When, however, denial of danger

was expressed in a failure to follow safety

procedures, it became highly maladaptive.

In concentration camps it was observed that

prisoners who could deny the inevitability

of death by selective inattention and emotional numbing, and carry on by helping

others, were most likely to survive. Those

who expressed denial by escape into day

dreaming and by not accepting the grim

realities soon perished.38

3. Dissociative states such as feelings of

depersonalization, derealization and detachment from one’s body, and amnesia

and fugues, which, like denial, are commonly associated with trauma. Patients

with multiple personality have a high incidence of conversion disorders.45

4. Development of procedures and methods

of study which established the organic nature of conditions once thought to be of

hysterical origin, such as the focal dystonias,

reflex sympathetic dystrophy and transient

global amnesia.

5. Investigation of the roles of brain damage

and cerebral hemisphere asymmetry in the

incidence of and lateralization of symptoms

in conversion disorders.

6. Sociocultural and epidemiological aspects

of mental illness.

Role of Violence

The relationship of violence to conversion disorders was studied in a series of investigations at the

Veterans Administration Hospital in Salem, Virginia and the Walter Reed Army Medical Center in

Washington, D.C.46–48 A majority, 70%, of patients,

including men and women, attributed their symptoms to an injury, or placed the onset in a traumatic

setting, even though the trauma may have been

minor and occurred months or years previously.

Reports included falls, wounds, blows, vehicle accidents, surgical operations, a dental novocaine injection, family quarrels, witnessing an act of violence,

and, in one instance, a voodoo spell. Women were

more apt to cite sexual violence, such as an attempted rape or seduction or a Lesbian solicitation.

In contrast, control subjects with organic impairments comparable to the conversion symptom did

not invoke trauma unless the disability had actually

been caused by an injury. Similarly, none of a group

of patients with anxiety states that served as another control attributed his illness to injury.

A content analysis of verbal language showed

that conversion subjects also used more words of

violence to describe their symptoms and experiences. Patients with hemisensory syndromes spoke

of a side as “dead,” and as feeling as if they had been

“cut in half.” Men who had been in vehicle accidents used more expressions such as, “smashed,”

“mashed,” and “killed” than controls who had sustained comparable accidents and injuries. A soldier

who developed a functional paralysis of his right

arm after bayonet practice characterized the exercise as “kill or be killed.” Violence was the metaphor through which the patient organized his experience, and his idea of what happened to him was,

in terms of the response of his nervous system, as

important as what actually happened. A decorated

veteran of the Korean conflict, the sole survivor of

an airplane crash in which 20 people had died,

described the screams of the dying and the smell of
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Conversion Disorders

the flesh of burning bodies, even though he had

been unconscious at the time.

The following case illustrates how the recall of

traumatic events and the idiom of violence may

serve as symbolic or metaphorical representations

of current problems, and how the intensity of such

recollections may vary with changes in the person’s

present circumstances. The case also indicates the

association of a conversion disorder and features of

a post-traumatic stress disorder.

Case Study 2: Forgetting Remembrance of

Things Past

A 44-year-old dairy farmer was admitted to the Salem

Virginia VA Hospital in 1963 with complaints of nervousness, blackouts, dizziness, headaches, and loss of feeling and weakness over the left side of his body. He stated

initially that the left-sided symptoms had come on during

World War II service in Italy after a shrapnel injury to his

left sciatic nerve.

On examination, there were mild residuals of sciatic

nerve involvement, along with marked weakness and

sensory loss of a functional type over the entire left side

of his body, reduced vision in the left eye, and diminished

hearing in the left ear. When asked how his symptoms

had begun, the patient gave a dramatic account of the

death of his commanding officer, and the loss of most of

the men in his company. He went on to tell how he had

been ordered to target a church in which German soldiers

were thought to be hiding. After the church had been

demolished, it was found to have been filled with women

and children. He had been continually troubled by recollections of the event and when he entered any church

became disturbed by the thought of the massacre.

The patient improved over the course of hospitalization, and at follow-up a year later he reported that he had

done well except for some irritability and nervousness. He

no longer complained of the loss of feeling over his left

side, and examination showed only a faint diminution of

sensation. He now attributed his nervousness to overwork, business problems, and difficulties with a brotherin-law on whom he had depended. He thought that his

left-sided symptoms had come on several years earlier

after he had done some heavy lifting on the farm. When

asked about his wartime experiences, he said he could

remember little or nothing about them.

Comment: In one situation a conversion symptom may

be associated with traumatic events; after the patient has

recovered he may have an amnesia for the traumatic

experience.

Denial

Patients denied concern over the emotional, social, and occupational problems that appeared connected with the conversion symptom. They might

deny fear of combat, job dissatisfaction, and feelings of incompetence. Some tended to resent psychiatric investigation and statements by examiners

that they did not have an organic condition. They

also showed no appreciation of the consequences of

the putative organic disease. The following cases

indicate how the traditional la belle indifference may

be regarded as a form of denial.

Case Study 3: Movements that Prevented A Move

A 41-year-old infantry platoon sergeant with 12 years

of active duty was hospitalized at Walter Reed Army

Medical Center in July 1991 because of bizarre involuntary movements that had come on in January after his unit

had been notified that they had been ordered from Germany to the Persian Gulf. He also complained of numbness and weakness of his left side since a head injury in

1984. Neurological examination revealed a staggering,

saltatory gait, and a left hemisensory syndrome with

jerking of his left limbs. A work-up including magnetic

resonance imaging (MRI) yielded no evidence of organic

involvement. During a Sodium Amytal interview, the

patient walked normally, but his symptoms soon recurred

and he refused another session. He had a cheerful,

unworried demeanor despite his objection to being on a

psychiatric floor and his demand to be seen by an expert

in Huntington’s disease, a condition that had been diagnosed by a German civilian neurologist.

The soldier had grown up in the rural South and had

less than a high school education. He gave a dramatic

family history of poverty, violence, and serious illnesses.

His father was described as having a bad temper that led

him into frequent fights and, when enraged, he had fits in

which he trembled all over. Mother did the whipping and

was very religious. Siblings were said to have illnesses

that included schizophrenia, a cerebral hemorrhage, and

neuritis with difficulty in walking.

Comment: The denial was shown in several ways. The

patient maintained a cheerful manner and lack of concern

for both his own and his family’s disabilities. The spectacular gait and bizarre involuntary movements may also

be seen in terms of adaptation, as a tragi-comic caricature

or parody of disease. While such extreme melodramatic

behavior is uncommon, many patients appeared unruffled

by their situation. Some may be unconcerned with the

conversion manifestation itself but are tense, withdrawn,

and even hostile.

Case Study 4: Denial by Bravado

A 27-year-old female U.S. Marine was admitted to the

hospital 2 weeks after she had passed out on a run at boot

camp. She complained of numbness of her left ankle and

toes and received a negative work-up for reflex sympathetic dystrophy. She developed weakness in her legs

and impaired walking and was diagnosed as Achilles

tendonitis. Examination showed functional weakness of
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394

both lower extremities and hyperesthesia with no evidence of spinal cord, root, or peripheral nerve disease.

She had difficulty in standing and could only walk on

crutches. Despite her condition, she was eager to return

to duty saying in rather belligerent fashion that she was

too tough to be laid up by a sprained ankle. She wanted

to serve in the U.S. Marines to fight terrorists, then join the

FBI [Federal Bureau of Investigation] to fight crime, and

then use the GI bill to become a coroner.

Comment: The case illustrates how an obviously incapacitated conversion patient may insist on returning to

duty, often with boasts of prowess and intent to wreak

mayhem on the enemy.

Dissociation

Conversion disorders have dissociative aspects

in that somatic and cognitive experiences may occur out of the sphere of conscious awareness. As in

the two cases cited above, patients may regard the

affected part of the body as outside and emotionally

irrelevant to the self. The following excerpt illustrates an acute dissociative reaction in the form of a

functional amnesia.

Case Study 5: A Fall From Battle

A 25-year-old U.S. Marine was evacuated from the

fighting in Panama after a fall on his head. For a period of

a week he did not know his name or anything of his past

life. He spoke with a Latin accent that he had not had prior

to his injury, and did not recognize his wife. There was no

anterograde amnesia; he watched television and was

able to remember what he had seen. He knew of

Mohammed Ali and Babe Ruth because he had seen them

on television since coming to the hospital. Neurological

study found no evidence of brain damage and his memory

suddenly returned.

Comment: More often the amnesia does not involve

such a profound loss of the data of personal identity, and

a patient may report no memory of an experience or

limited span of time. Commonly, the person states that he

will find himself in a certain place, and will have no

recollection of going there. Functional amnesia may

follow a fugue state, the essential feature of which is the

assumption of a new identity without awareness of the

previous identity. In the classical form the person is not

aware of his memory loss, and the condition often involves travel away from his base.

Organicity

Estimates in the literature of central nervous

system pathology in conversion disorders vary

widely depending on symptomatology, type of

medical facility, methods of investigation, and

criteria of organicity. The highest incidence of

62.5% is reported by Whitlock49 whose 56 patients

were studied, in most instances retrospectively, on

inpatient psychiatric services in England and Australia. The major categories of organicity were a

concussive head injury during the preceding 6

months and a history of epilepsy. A similar study

in Canada by Roy50 yielded evidence of neural pathology in only 16% of cases. At the other extreme,

is the report of about 1% of conversion disorders in

neurological patients admitted over 3 decades

to the National Hospital for Nervous Diseases,

Queen Square, London.51 Brandt52 found an incidence of 9% among over 4,000 neurological

patients admitted to a general hospital in Munich.

Pain and dizziness were among the most common

symptoms and this may account for the difference

from the Queen Square findings. Weinstein53 reported functional paralysis, sensory loss, and

involuntary movements in 16 of 200 soldiers

hospitalized for closed-head injuries with documented periods of unconsciousness followed by

disorientation, amnesia, and confabulation. Conversion manifestations appeared after these disturbances of consciousness had cleared, at intervals up

to 8 months.46

The author’s ongoing study of 90 patients with

conversion disorders admitted to the neurological

and psychiatric services of the National Naval Medical Center and Walter Reed Army Medical Center

(both in Washington, D.C.) has yielded evidence of

neural pathology in 20 cases. The criteria are objective clinical signs of brain damage confirmed by

laboratory findings, a head injury or anoxic episode

with loss of consciousness within the previous 6

months, or a documented history of brain disease.

Five patients had clear cut neurological conditions;

two had multiple sclerosis, two had cerebral vascular involvement (one with collagen disease), and

another patient had progressive supranuclear palsy

with dementia. Eleven patients had had head injuries with loss of consciousness or anoxic episodes,

that were momentary in most instances. Four of the

11 had computed tomography (CT), magnetic resonance imaging (MRI), or electroencephalogram

(EEG) abnormalities. Two patients had had a bona

fide seizure prior to developing psuedoseizures.

One had a dural sinus thrombosis with a persisting

abnormal MRI. A patient with pseudoseizures and

a functional left hemisensory syndrome had an

Arnold-Chiari malformation, and one soldier had a

history of childhood hyperactivity/attention-deficit disorder.

These data may be interpreted in a number of

ways. One is that organic neurological disease may
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Conversion Disorders

be misdiagnosed. Another is that there may be

functional elaboration of deficits caused by the brain

lesion. Third, brain injury may facilitate the dissociative process and lower the threshold for conversion disorders. On the other hand, there is no

correlation between the severity of brain damage

and the occurrence of conversion reactions. The

high proportion of head injuries reported may be a

reflection of the tendency of patients with conversion disorders to focus their problems on trauma.

Head injuries or other brain disease including seizures in childhood may contribute to less education

and lower socioeconomic status, both risk factors

for conversion disorders.

Laterality

Almost all 19th and early 20th century neurologists believed that hysterical phenomena occurred

predominantly on the left side of the body, and a

number of modern studies51,54,55 have confirmed an

asymmetry. Handedness was shown not to be a

factor.55 Several explanations, some based on investigations of hemisphere specialization in neurological conditions, have been offered. One is that the

right brain is specialized for the monitoring of somatic states and the mediation of negative emotional processes. A recent literature review56 of the

thalamic pain syndrome of Dejerine-Roussy showed

a significant predominance of right thalamic lesions in cases with lateralized pain. In contrast, the

incidence of the other components of the syndrome—hemiparesis, sensory impairment, ataxia,

and choreoathetosis—did not differ significantly in

the left and right groups.

Another approach draws on the analogies of

hysterical hemisensorimotor syndromes with

anosognosia and hemineglect, both of which occur

mainly as a result of right brain lesions. In the

various forms of anosognosia, the patient denies,

caricatures, or appears indifferent to his deficits,

and may even feel that the affected parts of the body

do not belong to him. In hemineglect, he ignores

stimuli and events on the impaired side of his body

and in circumambient hemispace. Patients with

hemineglect following strokes, brain traumas, or

mass lesions may show a midline split to all sensory

modalities, including vibration, and a disinclination to use the impaired extremities or look to the

affected side even though such movements can be

elicited in other contexts.57–59

One may speculate that patients with functional

hemisensorimotor syndromes show the affective,

subjective aspects of anosognosia and hemineglect.

They may feel that the affected side of the body is

dead, insensitive, or detached from the self. From

the standpoint of diagnosis, however, such patients

do not have tactile or visual extinction. Nor do they

bisect a line or draw a clock or human figure in

asymmetrical fashion, or show the eye shift to the

unaffected side on visual confrontation characteristic of organic visual neglect.

Epidemiology

Major conversion disorders occur predominantly

in the lower social classes, among the poor and less

educated,22,60–62 and in certain cultural groups. They

are also common in societies in which violence is an

important source of identity and mode of social

relatedness.47,63 The Salem, Virginia Veterans Administration Hospital was chosen for study because

of its high rate of conversion disorders. Over a 4-

year period in the 1960s, 25% to 30% of all patients

admitted showed conversion manifestations at some

time during hospitalization.

The patients were drawn mainly from the Appalachian counties of Virginia and West Virginia. The

region was rural but nonfarming, and had an ethnically homogenous (mostly old, Anglo-Saxon, white,

and Protestant) population. The decline of the

extractive industries of mining and logging had led

to economic depression. Educational facilities were

limited, and the average school attainment at the

time of the study was eighth grade.

Since the days of the Hatfields and the McCoys

down through the mine union wars, Appalachia

has had a tradition of violence. While the blood

feuds have ended, a high rate of murder and

nonnegligent homicide has persisted. Violence was

a form of communication, occurring principally

among relatives, friends, and acquaintances. Ownership of guns was universal and hunting and automobile racing the most popular sports. Violence in

the form of physical beatings and the instillation of

fears of ghosts and graveyards was a prominent

instrument of child raising. The theme of violence

pervaded religious beliefs—mainly of the Fundamentalist type. These emphasize divine punishment and forgiveness of sin, salvation and the next

world, and saw in physical catastrophes evidence

of the power of the Lord.

Attitudes toward health and illness were tied to

the idea of a dangerous environment. As the

economy dictated hazardous jobs, and safety standards were low, there was a high accident rate, and

men worked until they were disabled or laid off.

The manifestations of disability were a badge that
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indicated that the person had worked and suffered,

and many people grew up in a home with a disabled

or crippled relative who was receiving compensation. These conditions, along with the military

tradition of the region, produced a high rate of

enlistment in the armed forces, particularly the

combat branches, and the role of wounded or disabled veteran was a familiar, sanctioned, and rewarding one.

These features are present in some Latin American societies with their high homicide rates, male

macho roles, and violent, bloody religious imagery.

The so called ataque was not uncommon among

Puerto Rican troops, usually in noncombat situations. It was characterized by the sudden onset of

violent behavior, thrashing about, striking out and

pseudoseizures, with homicidal and suicidal ideation, and, in some cases, belief of being affected by

spirits of the dead. The attack lasted from a few

minutes to one half hour and was followed by

amnesia. It was brought on by feelings of rage,

frustration, and disappointment, and usually cleared

when the man was placed in isolation.64 Compton

and Jones65 showed that the syndrome (sometimes

called the Puerto Rican Syndrome) occurred in all

Hispanic military populations and appeared to be

culturally determined.

A major reason why conversion disorders have

occurred more commonly in women is that, historically, except in wars, women have been subjected to

more physical and sexual violence—much of it institutionalized—than men. Currently in the armed

forces conversion disorders occur with equal frequency in men and women.

DIFFERENTIAL DIAGNOSIS

The diagnosis of a conversion disorder depends

primarily on the neurological examination in which

the findings symbolize some traumatic experience

or conception by the patient of a loss of function, but

do not conform to a neuroanatomical or neurophysiological pattern. The existence of an emotional

conflict may not be helpful as anyone in a stressful

situation may have problems. Similarly, determination of secondary gain is difficult to evaluate as

soldiers with a variety of ailments may be seen as

deriving some benefit from them.

Motor Disorders

Loss of motor power appears as weakness or

paralysis of single limbs, paraplegia or paraparesis,

hemiparesis or hemiplegia. Quadriplegia as a conversion disorder is almost unknown. While the

patient cannot move a limb voluntarily, or fails to

exert sustained power on effort—so-called giveaway weakness—there are no postures indicative

of weakness. In the supine position, the leg on the

putatively hemiplegic side is not more externally

rotated nor is the foot more dropped than its fellow,

and when the upper limb is extended in pronation,

the thumb does not droop. There is likely to be a

Hoover sign in hemiplegia. When the supine putatively hemiparetic patient is asked to raise a leg

alternatively or sit up, he does not press down

harder with the heel of the good leg, as one would

expect if the weakness were of organic origin. There

is not the motor gradient characteristic of a cerebral

lesion in which the greatest weakness is in the most

distal muscles. In a hysterical hemiplegia the facial

and tongue muscles are spared. Also, a patient with

a hemiplegia may exhibit diminished power in turning his head to that side even though the action is

performed by the contralateral sternomastoid

muscle. He is apt to drag the leg or walk with a limp

rather than with the circumduction of an organic

hemiparesis. In hysterical monoplegia all movements about a joint are equally affected whereas in

peripheral nerve or radicular lesions there is a segmental distribution.

Disorders of Stance, Gait, and Balance

The classical astasia-abasia refers to the person’s

inability to stand (astasia) or walk (abasia) even

though other actions of the legs can be performed.

In the Romberg position, there is an increasing

amplitude of sway after a latency of a few seconds,

and the patient avoids falling by grasping the examiner or staggering across the room to gain support

from a wall. In walking there are exaggerated

efforts to maintain balance by using the arms as if

the patient were on a tightrope, or by flexing hips

and knees to gain a lower center of gravity. There

may be a fluctuation in performance, and the patient may walk as well in tandem or on his toes as in

more conventional forms of locomotion. Gait may

be very slow and hesitant with short steps and

apparent sticking of the feet to the ground. Unlike

the situation in Parkinson’s disease, the inhibition

is not overcome after the first few steps. Sudden

buckling of the knees may occur, usually but not
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Conversion Disorders

always, without falling. Other conversion manifestations (sensorimotor, visual, oculomotor, speech,

or pseudoseizures) may be associated. Chorea and

dystonia are the neurological conditions most likely

to be misdiagnosed. Also disturbances of gait and

balance can be caused by drugs, anticonvulsants, antidepressants, alcohol, sedatives, and tranquilizers.

Vertigo, the sensation of the apparent movement

of one’s body or of an object in one’s line of vision,

may accompany astasia-abasia, but as a presenting

symptom it is only rarely of hysterical origin. It is

much more common in anxiety, panic and phobic

states, and depression. Psychogenic vertigo is differentiated from disease of the vestibular system by

the absence of nausea and vomiting and of rotational vertigo with direction-specific falling. If a

complaint is of a rotational component, the absence

of concurrent spontaneous nystagmus under

Frenzel’s glasses, which suppress nystagmus by

fixation, suggests a functional etiology.52,66

Involuntary Movements

Tremor and myoclonus are the most common of

the involuntary movements of psychological origin. Tremor consists of oscillatory movements produced by contractions of reciprocally innervated

antagonistic muscles. Myoclonus is a quick involuntary jerk. These disorders usually have an abrupt

onset following a head or back injury, a car accident, a surgical procedure, or some emotional upset. Psychogenic tremor generally combines resting, postural, and kinetic components, and varies in

amplitude, frequency, and time of appearance. Both

tremor and myoclonus may be relieved by placebos, reduced when the patient is distracted, increased by attention, and associated with other

conversion manifestations such as sensory loss and

giveaway weakness in the affected limbs, speech

and gait disorders.67,68

Camptocormia is a postural disorder in which a

soldier presents with severe forward flexion of the

spine, often along with flexion at the knees and

dangling of the arms. The position persists in walking but disappears when the man lies down. He

complains of pain that he attributes to a back injury,

and there is often a family history of back disability.

A herniated disc or spinal stenosis is occasionally

found but these are not causes of the deformity69,70

although they determine its site.

Dystonia was formerly thought to be of psychological origin but studies in recent decades have

established it as a neurological entity. It is a syndrome dominated by muscle contractions frequently

causing twisting and repetitive movements, or abnormal postures that may be sustained or intermittent.71 It can be focal or generalized and includes

torticollis, involuntary movements of the thumb

and limbs, orofacial and mandibular dystonia,

blepharospasm, and dysphonia. Focal dystonia

also includes writer’s and piano and violin player’s

cramp and other specific task or instrument conditions. Electromyography reveals that reciprocal

muscle inhibition is impaired so that there is

cocontraction of agonists and antagonists.

The clinical picture may be bizarre—in dystonia

involving the legs the patient may be able to walk

forward but not backward. About 9% of cases are

preceded by trauma and remissions occur in 12% of

cases of torticollis.72 However, dystonic movements

and postures of psychogenic origin are rare.73 In

such cases the dystonic manifestations are apt to be

associated with peculiarities of gait and functional

types of sensory and motor loss. The following case

excerpt illustrates some of the diagnostic pitfalls

that may be encountered.

Case Study 6: The Wry Neck Recidivist

The patient was a 45-year-old field grade officer who

was referred to a base section hospital in North Africa with

a diagnosis of hysterical torticollis. The involuntary turning movements of his head to the left had come on while

he was awaiting a court-martial for alleged black market

dealings. The movements were interpreted as symbolic

of his unconscious wish to turn away from the problems.

Subsequent investigation, however, established a neurological diagnosis of torsion dystonia.

Comment: Stressful events may coincide with the onset of an organic neurological condition.

Sensory Disorders

Loss of sensation in conversion reactions involves

a diminution or absence of feeling over one side of

the body or in one or more limbs resulting in glove

and gauntlet, and sock and stocking distributions.

In hemisensory syndromes all or several modalities

are involved without the dissociation usually found

in cerebral lesions in which stereognosis, 2-point

discrimination, graphesthesia, and position sense

are more impaired than pain, temperature, touch,

and vibration. During testing for astereognosis, the

patient may manipulate the test object skillfully in

his fingers indicating intact proprioception but still

fail to identify it. There is commonly a midline

demarcation in which the patient feels all stimuli

less intensely on one complete half of the body,

perceiving the tuning fork differently on either side
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398

of the sternum and forehead, even though vibration

is transmitted through the bone. A midline split on

sensory examination is not necessarily present even

though patients complain of a loss of feeling over

the entire half of the body. The special senses are

also involved: on being tested the patient reports

poorer vision in one eye, reduced hearing in the

corresponding ear, and even less smell in one nostril and less taste on one side of the tongue.

The phenomenon of extinction elicited by the

method of double simultaneous stimulation is useful in distinguishing a hemisensory deficit of hysterical origin from one caused by structural brain

damage. Patients with pathology in one hemisphere may have normal or slightly reduced responses to touch and pinprick with a single stimulus to the side opposite the brain lesion, but when

bilateral simultaneous stimuli are applied sensation is extinguished or further reduced on the side

contralateral to the lesion. The responses of patients with a conversion disorder, however, are not

affected by the method of testing.

In conversion disorders involving single limbs

there is a loss of a sensory gradient. If impaired

sensation in the lower extremities is caused by a

spinal cord lesion, then vibratory sensation is most

impaired in the toes and less affected over the more

proximal areas. In conversion reactions, on the

other hand, the vibratory sensation may be not only

absent in the toes but over the ankles and knees.

The examiner should avoid suggesting to the patient that his sensation is impaired; hemisensory

syndromes can be created iatrogenically.

Visual Disorders

In no area of neurological examination is the

physician–patient interaction more likely to affect

results than in the plotting of the visual fields.

Fatigue, inattention, or suggestibility on the part of

the patient and overzealousness and impatience of

an examiner can produce abnormal visual fields

even in people who have no visual complaints, and

the findings may differ on successive examinations.

Functional visual field loss takes the forms of constricted or tubular fields in which the size of the

field does not vary with distance of the target, spiral

fields that progressively diminish during testing so

that only central fields remain, and focal field defects that do not follow an anatomical or physiological pattern. Tunnel fields may occasionally be found

in patients with frontal lobe tumors.

Functional blindness can be detected by normal

pupillary light reactions (impaired in blindness of

organic neurological origin except in cortical blindness due to bilateral occipital lobe lesions), by producing a blink response to visual threat, by eliciting

eye movements with an optokinetic tape or drum,

and by moving a large mirror to and fro and up and

down in front of the patient while observing eye

movements corresponding to the movement of the

mirror.74 The red glass test is particularly useful in

monocular blindness. The patient is asked to read

a line of alternating black and red letters with a red

glass placed over the good eye. Any reading of the

red letters must accordingly be done by the supposedly bad eye. Patients with functional reductions of

visual acuity can be shown to have normal vision by

retesting, encouragement, or subterfuges designed

to identify normal acuity.75

Hearing Loss

Functional hearing loss is indicated when the

behavioral response is inconsistent with auditory

findings on examination. Psychogenic deafness is

initially suggested if the patient speaks in a loud

voice and refuses to communicate except in writing.

Eye blink in response to a loud noise, or awakening

from sleep after a loud sound indicates that hearing is

present. More sophisticated procedures include delayed auditory feedback which normally disrupts

performance on reading aloud. In unilateral hearing

loss a tuning fork placed over the mastoid on the

affected side should produce hearing, via the good ear

through bone conduction, so the patient’s report that

he hears nothing indicates psychogenicity. The

Stenger test makes use of the observation in normal

persons that if identical signals differing in intensity

by more than 20 decibels are presented to each ear, the

sound appears to come from the ear in which the

intensity was greater. If a high-intensity signal is put

into the supposedly impaired ear at the same time that

a low-intensity stimulus is delivered to the good ear,

a failure of the good ear to hear indicates that there

is auditory function in the involved ear.76

Speech Disorders

Stuttering is the most common hysterical speech

disorder. It frequently occurs after trauma, and

may be preceded by a period of mutism. It contrasts

with conventional stuttering which begins in early

childhood and starts only rarely in adults. Conventional stuttering is variable, occurs in different situations, with different words, typically involves the

initial sound of a word, and does not occur in

singing or more automatic speech like greeting and
399

Conversion Disorders

counting. Conventional stutterers adapt with

avoidant measures such as the use of a substitute

word when they anticipate difficulty. Conversion

subjects are rigid and unvarying, stuttering in all

situations, and there may be associated jaw, face,

tongue, and vocal cord tremors. Other functional

disturbances include slow, labored, staccato, and

syllabic deliveries.

Pseudoseizures

The differentiation of pseudoseizures (also known

as psychogenic seizures) from bona fide epileptic

fits depends on a number of criteria, no one of

which is sufficient for an unequivocal diagnosis.77

Moreover, pseudoseizures may coexist with true

seizures (Table 15-1).

Onset Usually paroxysmal; may be preceded Usually paroxysmal; may be Often gradual; proby seizures of different muscles or preceded by aura of only longed, nonspecific

auras few seconds warning may occur

Postictal confusion Prominent Almost always present Often conspicuously

absent; patient may

be normal immediately after attack

Recollection of None Usually scant and most often Sometimes detailed

events none

Suggestibility None Rare Occasionally

Violent behavior None Rare; virtually always in Rare; but may be

response to restraint and highly directed

not highly directed

Weeping* None Very rare Common

Comparison with Relatively little variation in events Wide range of events, but Extremely wide range

known seizure most common are well of events with

types described bizarre and unusual

behavior

EEG during seizure Abnormal and changed from preictal Frequently abnormal Usually normal and unand changed from preictal changed from preictal

EEG immediately Almost always abnormal and Frequently abnormal Usually normal and unafter seizures changed from preictal and changed from preictal changed from preictal

Abnormal neuro- May be present (example: Todd’s May be present None

logical signs paralysis)

during seizure

Relation of attacks Prominent, especially in severely Usually related Usually unrelated but

to medical affected patients anticonvulsive

regimen medication may

increase frequency

of seizures

Nocturnal Common May occur Rare

occurrence

TABLE 15-1

CRITERIA FOR DIAGNOSIS OF EPILEPTIC AND PSYCHOGENIC SEIZURES

Characteristics Generalized Tonic Clonic Seizures Complex Partial Seizures Psychogenic Seizures

*

Source: Bergen D, Ristanovic R. Weeping as a common element of pseudoseizures. Arch Neurol. 1993;50:1059–1060.

Adapted from Desai BT, Porter RJ, Penry JK. Psychogenic Seizures: A study of 42 attacks in six patients, with intensive monitoring.

Arch Neurol. 1982;39:207-208.
War Psychiatry

400

More recent studies have shown that frontal lobe

seizures from mesial and orbital foci in which vocal

profanities and obscenities, rocking, and pelvic thrusting are apt to occur and seizures arising from the

supplementary motor area with thrashing movements

and tonic posturing are particularly apt to be mistaken for psychogenic seizures. They are distinguished

from the latter principally by short duration (usually less than a minute), stereotypy and nocturnal

occurrence, as well as EEG and MRI findings.78–80

Amnesia

Amnesia is a loss of memory for periods of time

and personal experiences, rather than inability to

remember facts and procedures. Amnesia may

occur on an organic or functional basis, and usually

follows some interruption of consciousness or emotional trauma. Anterograde amnesia (AA) refers to

the period of time following the acute event over

which the patient is unable to retain new information, and for which he later has no memory. Retrograde amnesia (RA) refers to the period prior to the

acute episode for which the person reports no

memory. Following loss of consciousness from a

concussion or other brain injury there is both an AA

and an RA, even though the RA may be very brief,

and the patient may remember everything up to a

few seconds before impact. One does not remember

the blow or other agent causing loss of consciousness. If, however, the patient recalls and describes

the crash of the car or the bursting of a shell, the

inference is that he did not lose consciousness, and

even though he may state that he does not then

remember anything until he found himself in a

clearing station or hospital, unable to walk or talk,

it is likely that the amnesia is not directly caused by

brain injury.

The profound amnesias of dissociated and fugue

states such as that described in Case Study 5 are

differentiated from the amnesias of brain injury

by the loss of data of personal identity and the

exclusively retrograde character of the memory loss.

Even when the RA following brain damage

is extensive, the person knows his name, address,

occupation, religion, and other autobiographical

information. He may not remember his actual

marriage ceremony, but he knows he is married

and recognizes his wife. He may not remember

actually enlisting, but he knows he is in the U.S.

Army. Also most organic amnesias show a temporal gradient in that more remote events are recalled

better.

Amnesia resulting from alcoholic intoxication

usually covers only the period of intoxication and

prolongation beyond that period suggests functional elaboration. Transient global amnesia (TGA)

should be considered in cases of sudden onset in

persons over the age of 40. TGA involves the sudden occurrence of a marked anterograde and variable retrograde amnesia, typically accompanied by

bewilderment and agitation, with the patient repeatedly asking the same questions. Data of personal identity are retained, and immediate recall is

preserved. The condition clears within hours. The

cause is unknown, but a migrainous etiology is

likely.81

Simulated Amnesia

Patients may simulate, exaggerate, or dramatize

memory loss. Useful but not infallible aids in distinguishing such states are:

1. Absence of a gradient of difficulty in that

subject may do as poorly on a difficult task

as an easier one.

2. Responses may be very slow.

3. Recognition is not better than recall.

4. Immediate recall, which is intact in most

organic conditions, is involved.

5. Performance is not improved with cues and

clues.

6. Elements of a Ganser syndrome may be

present.

Ganser Syndrome or Pseudodementia

In 1898, Sigbert J. Ganser, a German psychiatrist,

described four prisoners with episodes of clouding

of consciousness, disorientation, hysterical conversion symptoms, hallucinations, a recent history

of head injury or typhus, and vorbeireden.

82 The

last feature consists of “talking past the point,” in

which the patient gives approximate answers

such as stating that 2 plus 2 are 5, and calling a blue

object pink. The behavior was of short duration

and subjects were later amnesic. The syndrome

has occurred not only in prisoners but in persons

awaiting trial, in military personnel facing disciplinary action or being otherwise embittered with

military life. The complete syndrome is only rarely

present but fragments, particularly vorbeireden,

are common. Patients state that the capital of

France is Marseilles or may draw a clock with

the numbers reversed. Responses may be very
401

Conversion Disorders

slow. Violence and suicidal gestures may occur.

Malingering is often suspected, as patients seem

to be simulating insanity, or exaggerating a psychotic experience. In recent years, cases with Ganser

features have been reported following not only

head injury, but also strokes, brain tumors, and

acute psychosis, and have occurred in women as

well as men.83,84

TREATMENT

In the treatment of conversion disorders, the

major emphasis should be placed on removal of

symptoms. If these are not cleared, they take on a

life of their own, and persist even after the underlying emotional problems are no longer relevant.

These emotional problems are rarely “deep” in the

sense that they represent repressed unconscious

conflicts, but are usually situational. In general, the

most effective treatments are those that emphasize

affect and relatedness rather than insight. These

involve the induction of a state of mind or milieu of

brain function in which affect is released and the

person can reformulate stressful experiences in symbols and imagery. This may come about in the

context of a rapport with the therapist, via the

product of trance state by hypnosis, and through

the alteration of brain function provided by such

drugs as Sodium Amytal. The following three cases

are illustrative.

Case Study 7: Abreaction through Confession

A 20-year-old combat infantry private first class (PFC)

was seen in April 1969 at Phuoc Vinh, Vietnam by Captain

[later Major General] James H. Rumbaugh because of a

complete paralysis and loss of feeling in his left upper

extremity. He reported that he had tripped over a tree

trunk and landed on his left shoulder. Because of soreness and some deviation of his head to the left he was

taken to a hospital, put in head traction, and given a soft

collar. On the night following his discharge his unit was

mortared. He rolled out of his bunk, fell on his arm, and

“tore it up so bad” that he had to go back to the hospital.

Neurological examination now showed a functional paralysis of the entire left arm and a sensory loss for all

modalities which included the shoulder area. There were

two circumscribed burns on the left forearm where the

soldier had not felt a lit cigarette. Medical history disclosed that after lifting paper at a factory, a year prior to

enlistment, he had “messed up” his back and had been

unable to move his legs or walk for several weeks.

The patient stated that he had been in service for 9

months and had gone to jump school at Fort Benning.

When asked why he had gone he said that it was to do

something outstanding for the glory of it. He had been

born in rural Tennessee and had graduated from high

school in Michigan where his father had become an

automobile worker. He had gotten along well with his

parents, but described his father as having a high temper.

He and his brothers would get beaten with a switch or a

strap, particularly when his father had been drinking. He

was devoted to his mother whom he depicted as suffering

from “heart spells” and as very religious.

A few hours after the initial interview, the soldier approached Captain Rumbaugh to say that there was something on his conscience. With considerable emotion he

confessed that the jump wings he was wearing were not

his own, but had been given to him by a boy whom he had

met on the plane. He was told he could still be an

outstanding soldier, and Captain Rumbaugh assured him

that very soon feeling and then motor function would

return. The next day he had pins and needles sensations

in his fingers, followed by twitches in his thumb. At the end

of a 2-week period he had completely recovered. Followup from brigade surgeons indicated a successful return to

duty.

Comment: In this case the development of the conversion symptom may have been facilitated by the hospitalization and the orthopedic procedures.

Hypnosis and abreaction through the intravenous administration of barbiturates are indicated

when the patient has not responded to suggestion

and encouragement. Hypnosis is indicated especially in subjects with a high-induction profile

(HIP).85 The HIP is an indicator of hypnotizability

consisting of a biological component, the ability to

maintain upward gaze during slow lid closure, and

a psychophysiological one, the capacity for arm

levitation. According to Spiegel and Spiegel,85 the

highly hypnotizable individual has a reliance on

feeling rather than reasoning, a tendency to live in

the present, and a capacity for intense focal concentration. These features are enhanced in combat.

Case Study 8: Revisualization of Trauma

A medic, seen by Captain Herbert Spiegel during

World War II, was returned from a battlefield in Tunisia

with inability to use his legs, despite the absence of

organic findings. He and his unit had come under heavy

fire, and, after the sergeant ordered retreat, the soldier

heard the cry of a friend for help, and saw the foot of

someone who might have been the friend lying behind a

rock. However, he obeyed the order and retreated and his
War Psychiatry

402

friend never returned. He was overwhelmed with remorse

at not having tried to rescue him. The man was highly

hypnotizable and was able to readily regress to the past.

He was instructed to revisualize the scene of leaving the

battlefield with one modification, that the foot he had seen

was facing downward, with the implication that the man

was already dead. The soldier came out of the trance with

an exhilarating sense of “discovery” that his friend could

not have been saved. Within a few days he regained his

ability to walk and returned to active duty.85(p140)

Comment: In combat areas where alertness and mobility are important, hypnosis is in some ways preferable to

techniques involving barbiturates. Hypnosis does not

require venipuncture or sterile procedures and precautions against respiratory and circulatory depression, and

is not followed by drowsiness and ataxia. An occasional

subject becomes agitated and violent with barbiturate

administration, while in hypnosis the degree of abreaction

can be controlled. Also, posthypnotic suggestions may be

made for the handling of anticipated symptoms.86,87

The Amytal interview is indicated in situations

in which the patient is not communicative and related, especially in cases of stupor, muteness, and

deafness. It is also preferable to hypnosis when

there is lack of motivation, and where there is an

inability or unwillingness to focus attention.

Case Study 9: Abreaction in Dramatic Metaphor

An 18-year-old radio operator with 6 months service

was evacuated to Walter Reed Army Medical Center from

Germany because of difficulty in articulation. He spoke in

garbled fashion clicking his tongue against the roof of his

mouth. The symptom had come on the day after receiving

a painful novocaine dental injection and had gotten worse

over the next 2 months. The soldier was from a rural

Southern area and had had 4 years of high school.

Under Sodium Amytal he became very drowsy but

recovered to speak understandably. He told of his dissatisfaction with his job, the shock of seeing black men with

white women. He described how upset he was when he

found that the dentist was a black woman. He went on to

say how worried he was about his mother, who had no one

to take care of her. She had told him that she, too, had a

burning in her mouth after dental work. He was vague

about his father who, he said, had been killed by the Mafia.

He, himself, had almost been killed in an accident but had

been saved by a miracle. The patient spoke normally but

the following day had relapsed halfway. Following a leave

home, he talked normally. A psychiatric evaluation noted

dependent and avoidant personality traits and he was not

returned to overseas duty.

Comment: The case illustrates how, under the conditions of brain function supplied by a barbiturate, the

soldier could restructure the problems of job inadequacy

and homesickness in metaphors of race, violence, and

filial devotion.

The Amytal procedure is helpful in the detection

of volitional elements and malingering. Such patients may become excessively drowsy even before

there is a sufficient amount of the drug to have any

physiological effect. The subject may keep his eyes

tightly closed when the examiner is eliciting eye

movements and may not answer questions or may

respond in inaudible fashion.

The Amytal Test88,89 also serves in the diagnosis

of brain disease. Prior to injection the patient is

asked a series of questions dealing with orientation

and awareness of impairment, and answers are

recorded. (If the patient is already disoriented this

is indicative of brain dysfunction and the procedure

is not indicated.) The drug is then introduced

intravenously at a rate of 50 mg/min until errors in

counting backward, slurring of speech, mood change

(usually euphoria), and nystagmus are observed.

The questions are then repeated. One or more

persisting errors constitute a positive result indicative of organic brain dysfunction. Patients without

brain damage remain oriented and aware of impairment throughout with only occasional transient

self-corrected errors.

Case Study 10: Misdiagnosis Revealed by the

Amytal Test

A 44-year-old naval petty officer jet mechanic with 19

years active duty had a 10-year history of reduced color

vision that came on while he was on sea duty off Vietnam.

It became difficult for him to work with color-coded wires,

and subsequently he became unable to move his eyes.

Most recently he had complained of difficulty in remembering names and telephone numbers. Routine mental

status was within normal limits and on neuro-ophthalmological examination he could not move his eyes laterally or

vertically on voluntary effort, but some movement was

noted when he was distracted. Optokinetic nystagmus

was obtained and the vestibular ocular reflex was normal.

A diagnosis of conversion disorder was made.

He was given the Amytal Test at the National Naval

Medical Center in Bethesda. He answered the preinjection

questions accurately, and these were repeated after the

administration of 300 mg of the drug. He became disoriented for place, stated repeatedly that he was in Pensacola,

a former duty station, and was also disoriented for month

and year. Subsequent MRI showed evidence of bilateral

occipital lobe lesions, and he went on to develop a frank

dementia.

Comment: This case illustrates the value of the Amytal

Test in detecting neural pathology in cases in which routine

examination and laboratory tests have been normal.

When soldiers do not respond to therapy there

arise questions of associated brain damage, depres-
403

Conversion Disorders

sion, or mechanisms beyond the original dissociative process that are not entirely out of conscious

control. It is uncommon for a patient to manufacture symptoms out of whole cloth, but the idea of

incapacity has been implanted by the initial injury,

real or fancied, and after separation from his or her

group, the conversion symptoms symbolize and maintain a new identity as a disabled soldier. This role

is reinforced by each neurological or orthopedic

examination, and by the prospect of secondary gain.

After a conversion symptom has been present for

weeks and the soldier has been evacuated, it is

unlikely that he will return to combat. The emphasis should now be on the avoidance of procedures

that support the idea of physical disease or increase

secondary gain. Hospital privileges should be made

dependent on clinical improvement, and the prospect of another assignment or a favorable discharge

held out. Certain hysterical conditions such as

camptocormia are notoriously resistant to treatment and such patients should generally be

promptly separated from the service.

mediately, a recent wound or injury requiring hospitalization.

Conversion disorders are not disease entities but

signs and symptoms. Their character and incidence

have varied over the centuries with the forms of

trauma, cultural change, and the degree to which

the behavior is reinforced by society. One no longer

sees the stigmata of the Crucifixion, or the attitudes

passionelles of Charcot’s day. Conversion hysteria

was the hallmark of World War I, exhaustion featured World War II, and post-traumatic stress disorder came out of Vietnam. Conversion reactions

occur in the course of a number of conditions: posttraumatic stress disorder (PTSD), adjustment disorders, depression, multiple personality, Axis II disorders, and brain damage. The roles of brain

dysfunction and hemisphere specialization, and the

physiological mechanisms of dissociation are as yet

not well understood; but, depending on the circumstances under which people are exposed to threats

of death and mutilation and loss of personal integrity, then dissociative processes in the form of conversion disorders, PTSD, or some clinical syndrome

yet to be described will appear.

Conversion disorders have historically been associated with violence. They have been attributed

to the malign influence of devils and witches, to

divine wrath, to the sexual abuse and forcible subjugation of women, to industrial trauma, and to

shell shock in war.

Patients with conversion reactions describe their

symptoms in idioms of violence, ascribe them to

an injury, and depict their onset in a violent setting, even though the traumas may have been

relatively minor and removed in time. The conversion symptom is a symbolic representation of

a felt disability or a traumatic experience. The

language, verbal and gestural, imparts meaning

and a feeling of reality not only by reason of

the trauma itself, but because violence and the

anticipation of violence have been such important elements in patterns of social relatedness.

There is predisposition not in the sense of mental

illness or personality disorder—although these

are often deduced after the fact—but because

of lower class status, limited education, cultural

tradition, family violence or physical disability,

previous conversion episodes, and, more imSUMMARY AND CONCLUSION

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