J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(1):7-31. Original Article

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1 7 J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(1):7-31 Original Article Study of Frustration in Adolescents with Conversion Disorder Narayana Keertish MD, Indira Sharma MD Address of correspondence: Dr. Narayana Keertish, No. 619, 2nd Cross, RBI Layout, 7th Phase, J P Nagar, Bangalore keerthish_shetty@rediffmail.com. ABSTRACT BACKGROUND: Conversion disorder has been found to be the most common neurotic disorder in children and adolescents. The relationship between temperament and conversion disorder is well documented, but there is dearth of Indian studies directed at studying the psychosocial and temperamental/ personality factors in adolescents with conversion disorder. OBJECTIVE: Aim of the study was to assess the reactions of adolescents with Conversion Disorder to frustrating situations as measured by the Rosenzweig s Picture- Frustration Study. METHODS: Thirty school going adolescents with Conversion Disorder, diagnosed as per DSM-IV-TR criteria, and thirty healthy matched controls, comprised the sample. Patients and controls were assessed by the Rosenzweig s Picture-Frustration Study. RESULTS: The patient group was superficially well adjusted, as evident by the Group Conformity Rating score. However, the patient group was deficient in other areas, both in the type (higher scores on obstacle dominance) and direction of aggression (lower scores

2 8 on imgression). The patient group also had deficiency in the superego defense patterns (lower scores on intropunitive deviant and combination of intropunitive deviant and imgression) and pattern of 3 most frequent responses (higher frequency of extrapeditive scores). CONCLUSION: Adolescents with conversion disorder, instead of evading the frustrating situation, are excessively pre-occupied with the barrier causing frustration. Thus, efforts to overcome this deficiency should be a part of management of conversion disorder in adolescents in order to achieve early recovery and to prevent relapse. KEY WORDS: Conversion Disorder, Adolescents, Frustration Introduction Conversion disorder is defined as a deficit of sensory or motor function that cannot be explained by a medical condition and where psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of symptom or deficit is preceded by conflicts or other stressors [1]. Conversion disorder has been found to be the most common neurotic disorder in children and adolescents [2-6]. Although the incidence and prevalence of conversion disorder is uncertain, it has been reported to vary from 3%-5% [1,7]. Indian studies have reported incidence of childhood conversion disorder in up to 31% of inpatient and 14% of

3 9 outpatient samples [8]. Conversion disorder is more often seen in females than in males [9,10]. Nearly one out of five children will have a behavioural or emotional disorder at some time in their life [11]. Role of temperamental/personality traits The relationship between temperament and psychopathology is well documented. Temperament influences the development and psychopathology in two ways: as a determinant of psycho-neuro-physiological vulnerability and as a determinant of parentchild interaction in the form of varying the quantity and quality of care evoked by the temperament of the child [12]. Children with conversion disorder were found to have low distractibility [13]. Low distractibility may actually mean low soothability i.e. such children, temperamentally, take longer to come out of a distressed state and remain in distress for relatively a longer period in the face of day-to-day distress [14]. Ishikura and Tashiro reviewed 9 patients with dissociative disorder and 10 patients with conversion disorder and found that the patients of both groups, who encountered troubles in their lives, were found to have frustrated needs [15]. Their symptoms tended to be accompanied more often by frustrations regarding a 'need for love' in the dissociative disorder group and by frustration in the need for 'self-esteem and self-actualization' in the conversion disorder group.

4 10 Psychological investigation of a teenager girl with conversion disorder with mixed presentation revealed that she had an IQ of 95, rich expressive language, good social adaptability, low frustration tolerance, egocentrism, a desire to make a good impression and to be the centre of attention, high suggestibility and histrionic characteristics [16]. The Freudian concept that personality was determined by a dynamic interplay among the id, ego and superego, supports the idea that conversion symptoms occur as a result of inability to repress a conflict between the id and the superego [17]. According to psychoanalytic theory, conversion disorder is caused by repression of unconscious intrapsychic conflict and conversion of anxiety into a physical symptom. The conflict is between the instinctual impulse like aggression or sexuality and the prohibitions against its expression [18]. It is evident from the above review of literature that the temperamental/personality factors namely; low distractibility, low activity, low emotionality, low frustration tolerance and the intrapsychic conflict between the instinctual impulse like aggression (Id) and the prohibition against its expression (Superego), have been implicated in the causation of conversion disorder in adolescents. Hence, a systematic study of the reactions to frustrating situations will not only help in understanding the factors that influence the psychological milieu of children with conversion disorder, but also aid in planning effective management and prevention of relapse. The present study was conceived with the aim of studying the nature of frustration (reactions to frustrating

5 situations) in adolescents with conversion disorder by Rosenzweig s Picture-Frustration Study. 11 The research hypothesis (H1) for this study was: There is no significant difference in the nature of frustration of adolescents with conversion disorder and normal healthy matched controls, on reactions to frustration by Rosenzweig s Picture-Frustration Study. Methods Sample The patient group comprised 30 patients in the age group of 12 to 18 years, diagnosed to be suffering from conversion disorder as per criteria laid down in DSM-IV-TR (American Psychiatric Association, 2000), who attended the outpatient psychiatry section (adult and child) of the University Hospital, Banaras Hindu University, Varanasi, India, Varanasi from March 2008 to July Patients with co-morbid psychiatric illness or major general medical condition, Intelligence Quotient (IQ)/ SQ (Social Quotient) of less than 70 and those not going to school were excluded from the study. The control group comprised an equal number of apparently healthy children and adolescents matched with the patient group on age, sex, socio-economic status, domicile and educational status. Children and adolescents with a score of 10 or more on the Childhood Psychopathology Measurement Schedule [19], IQ/ SQ of less than 70 and

6 those not going to school were excluded from the study. Consent was taken from parents /guardian and children from both the groups to participate in the study. 12 The Indian adaptation of the Rosenzweig Picture Frustration study [20] was used to study the nature of frustration in adolescents with conversion disorder. The Rosenzweig Picture- Frustration study is a controlled projective technique, primarily intended to measure reactions to frustrating situations. It was developed as a result of experiments with repression and frustration carried out by Rosenzweig [20]. The Rosenzweig Picture-Frustration study was adapted and standardized for use in India by Udai and co-workers [20]. While preparing the Indian adaptation, care was taken to retain the original situations with as little modification as necessary to make the situations acceptable in the Indian culture. It is intended for use with adults, but can be used with adolescents also. The scoring reliability was quite high, the percentage of agreement increasing to 98% after discussions [20]. Stability co-efficients ranged from 0.27 to 0.82 and consistency values from 0.46 to Methodology Each patient was assessed in detail on a structured proforma which had items related to socio-demographic data, psychiatric history, and physical and mental status examination. IQs/ SQs of the adolescents were assessed with Bhatia Battery of intelligence [21] or Vineland Social Maturity Scale [22].

7 13 Each patient and control was assessed by the Indian adaptation of the Rosenzweig Picture-Frustration study. The study consists of 24 cartoon like drawings representing frustrating situations. In each of the pictures 2 people are shown talking. The words said by one person are given. The subject is required to imagine what the other person in the picture would answer in that situation. The very first reply that comes into the mind is to be told or written. The subject is to work as fast as he can. General principles of the study It is assumed as a basis for P-F study that the subject unconsciously or consciously identifies himself with the frustrated individual in each pictured situation and projects his own bias in the replies given. Scores are assigned to each response as to the direction and type of aggression. Directions of aggression Directions of aggression included are: 1) Extragression or E-A- in which the aggression is turned on the environment 2) Introgression or I-A- in which it is turned by the subject upon himself; 3) Imgression or M-A- in which aggression is evaded in an attempt to gloss over the frustration. Types of aggression Types of aggression included are:

8 14 1) Obstacle Dominance or O-D- in which the barrier occasioning the frustration stands out in the responses 2) Ego Defence or E-D- in which the ego of the subject predominates 3) Need Persistence or N-P- in which the solution of the frustrating problem is emphasized. Group Conformity Rating (GCR) is a measure of conformity of an individual score to the modal responses of his group. It may be regarded as one measure of the individual s adjustment to a normal group. The total E-D score may be said to represent strength or weakness of the ego, while the N-P score may show adaptive adequacy. Super ego factors and patterns Superego (S-E) patterns were calculated to provide a measure of a subject s defensiveness. The superego deviants E and I were considered in relation with factors E and I and the category M-A. E is a variant of extrapunitive (E) in which the subject aggressively denies that he is responsible for some offense with which he is charged. I is a variant of intropunitive (I) in which the subject admits his guilt, but denies any essential fault by referring to unavoidable circumstances. M-A (Imgression) refers to evasion of aggression in an attempt to gloss over the frustration. Trends Trends are change of response types with recognizable consistency to any other mode, and even to change back again or to some third kind of behaviour before reaching the

9 15 end. The formula for calculating the value of the trend is (a-b)/ (a+b), in which a is the amount of factor in the first half of the test and b is the amount of factor in the second half. The total number of possible trends is 15, of which each may be positive or negative. 1) E, I, M 2) E, I, M 3) e, i, m 4) E-A, I-A, M-A 5) O-D, E-D, N-P Trends which were not significant as per the significance table given in the manual were reported as None. Total Pattern In calculating the total pattern, the three factors occurring most frequently, regardless of the type or direction of aggression, were entered in the order of their frequency and related to each other by symbols greater (>), lesser (<) or equal (=). Subsequently, the frequency of the three most commonly occurring factors were tabulated separately for the control and the patient group. Comparisons were undertaken on the nature of frustration on the Rosenzweig s study between the adolescents with conversion disorder and the control subjects. Chi-square and Independent samples student t tests were used for the statistical analysis.

10 16 Results I. Sample characteristics: Majority of patients were females and Hindus with rural background. All of them were unmarried and educated. Due to rapid economic growth in recent past, it was considered appropriate to classify socio-economic status (SES) based on per-capita income. About half of the patients hailed from low and low middle SES. The remaining patients were from higher SE strata. There was no significant difference between the patient and the control groups on sex, domicile, marital status, religion and SES (table 1A).

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12 There was no significant difference between the patient and control groups with regard to age and years of schooling (table 1B). 18 II. Clinical characteristics of the patient group: The mean age of onset of illness was (range = 9-18) years. Patient group had a mean duration of illness of (range= 1-260) weeks. 93.3% (N=28) presented as pseudoseizures, 3.3% (N=1) with gait abnormality and 3.3% (N=1) with mixed presentation). Major life events occurring in the 4 weeks period preceding the illness were considered as precipitating factors. Precipitating factors were observed in 56.6% (N=17) of the patients.

13 19 III. Comparison of patient and control groups on Rosenzweig s Picture-Frustration Study: Group conformity rating The mean Group conformity rating (GCR) of the patient group, was modestly high (mean ± 11.13; Range = 42-79). It did not differ significantly from the control group (table 2). Direction of Aggression The mean imgression score of the patient group was found to be significantly lower than that of the control group (p=0.021). There was no significant difference between the patient and the control groups on the mean extraggression and introgression scores (table 2).

14 Type of Aggression The mean obstacle dominance score of the patient group was significantly higher than that of the control group (P=0.023). There was no significant difference between the mean ego defence and the mean need persistence scores of the patient and control groups (table 2). 20

15 Compared to the control group, the patient group had a significantly lower mean values for the super-ego factors/ patterns, I (p=0.033), E + I (p=0.027), and M-A + I (p=0.003) (table 3). Trends In majority of the patients [19 (63%)-30 (100%)], one or more of the trends were absent ie None. There was no significant difference (p>0.05) between the patient and the control group on presence of positive (EA & MA) and negative (E, IA, MA, OD and ED) trends (Table 4), The frequency of other trends was low and did not permit statistical comparison. 21

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17 23 Total Pattern It may be noted that 2 or more than 2 factors amongst the 3 most frequent ones, had equal frequency in some of the subjects. Therefore, the total number of factors shown in the table is more than 90. When the total pattern of responses was examined it was observed that the frequency of E (extrapeditive score) was significantly higher in the patients group than in the control group (0.004). There was no significant difference between the patient and the control groups with regard to other factors. Discussion The present study was a modest attempt to study frustration in adolescents with conversion disorder presenting at the outpatient psychiatry Section of the University Hospital, Banaras Hindu University, Varanasi. The University Hospital caters to a huge population hailing from Eastern Uttar Pradesh, Chattisgarh, Jharkhand, Bihar, Madhya Pradesh and even Nepal. In the present study, reactions to frustrating situations were assessed with the help of Rosenzweig s Picture Frustration Study. The test was administered on an individual basis because of the opportunity it provided for enquiry, making scoring and interpretation more reliable. Group Conformity Rating (GCR) is the measure of conformity of an individual score to the modal responses of his group. The patient group had modestly high mean GCR

18 (61.67), which did not significantly differ from the mean GCR of the control group, indicating that on this measure the patient group had an adequate level of adjustment. 24 The patient and the control groups were compared on the direction of aggression in the sample. It was observed that patients had significantly lower mean imgression (M-A) score, compared to that of the control group. The extragression (E-A) and the introgression (I-A) scores did not differ significantly between the groups. This finding suggests that the patients did not evade the frustrating situation by attempting to gloss over it. Instead, they either directed their aggression on to the environment (E-A) or turned the same upon themselves (I-A). These types of reactions to frustrating situations are indicative of poor adjustment and coping.

19 Further analysis was done to explore different types of aggression, namely; obstacle dominance (OD), ego defence (ED) and Need persistence (NP) in the patient and the control groups (table. 5). The mean OD score of the patient group was found to be significantly higher than that of the control group. The mean scores of the ED and NP of the two groups did not differ significantly. This finding indicates that the patients were excessively preoccupied with the barrier causing frustration, which may indicate 25

20 26 anxiety and embarrassment. The OD scores of the patient group were contributed predominantly by higher E scores in the patient group. Extrapeditive (E ) scores are given for responses in which presence of the frustrating obstacle is insistently pointed out. Super-ego patterns are important as they provide a measure of the subject s defensiveness, either in denying the commission of the wrong (E), or in repudiating the reprehensible motivation connected with such behaviour (I) (Udai & Devi, 2006). The superego deviants were considered in relation to E (extrapunitive), I (intropunitive) and the category M-A (imgression). M-A and I were considered together as superego pattern, as both involved absolution from blame by either excusing someone else or by excusing oneself. It was interesting to note that the intropunitive deviant (I) was significantly lower in the patient group when compared to the control group. The E (extrapunitive deviant), however, did not differ significantly between the two groups. It follows that the patient group had weaker superego. While the control group admitted guilt, but denied any essential fault by referring to unavoidable circumstances, the same pattern was observed to a much lesser extent in the patient group. When I and E were considered together, similar findings were observed with patients having lower mean score than the control group. This was mainly because of the higher mean I score in the controls. Also, patient group had significantly lower scores compared to the control group when a combination of M-A and I were considered. This again suggests that superego defences of the patients are weaker when compared to that of controls.

21 27 As it is possible for subjects to change with recognizable consistency to any other mode, and even to change back again or to some third kind of behaviour before reaching the end, the protocols of the patients and controls were analysed for any significant trends. Five different types of trends, with total 15 trends, each of which could be positive, negative or none, mentioned in the foregoing chapter, were examined. A positive trend (, away from) is one in which a factor/ category predominates in the first half of the record; the opposite (, towards) is a negative trend. Trends not significant were recorded as none. In the majority of patients, one or more trends were absent i.e. none. Among the trends found, there was no significant difference when the patient and the control groups were compared. This finding suggests that by and large, the responses of the patients to frustrating situations were consistent as no significant difference was observed between the responses in the first half of the test compared to the second half of the Rosenzweig s Picture-Frustration Study. The total pattern of responses is significant as it provides information on the three most frequent responses seen in the subjects. The frequency of E (extrapeditive score) was significantly more in the total pattern of the patients than that of the control group (p = 0.004). There was no significant difference between the patient and the control groups with regard to other factors. Higher E scores indicate that the presence of the frustrating obstacle was insistently pointed out more frequently by patients than controls. This finding is in keeping with higher mean score on OD in the patient group.

22 28 Conclusion Hypothesis H1 is rejected and it is concluded that significant differences exist between the patient and the control group on reactions to frustrating situations as measured by the Rosenzweig s Picture Frustration Study. It was observed that, although the patient group was superficially well adjusted, as evident by the Group Conformity Rating score, the patient group was deficient in other areas. The patient group had deficiencies, both in the type (higher scores on obstacle dominance) and direction of aggression (lower scores on imgression); superego defence patterns (lower scores on intropunitive deviant and combination of intropunitive deviant and imgression); and pattern of 3 most frequent responses (higher frequency of extrapeditive scores). Thus, efforts to overcome the deficiencies should be a part of management of conversion disorder in adolescents in order to achieve early recovery and to prevent relapse. These conclusions of this study are tentative in view of lack of previous comparable data and limitations mentioned below. Limitations of the study 1. Since only school going adolescents were selected for the study, the findings in the Rosenzweig s P-F Study cannot be generalized for the adolescent population not attending school. 2. The adult form of the Rosenzweig s P-F study with adult norms has been used in this work. However, the authors themselves have mentioned that the same can be used in adolescents.

23 29 3. Group Conformity Ratings were available only for 12 of the 24 items of the Rosenzweig s P-F Study. Future directions Special efforts should be made to overcome the above mentioned limitations. Further work should be directed at studying reactions to frustration in association with important psychosocial variables such as classroom environment, home environment, sports/ extracurricular activities and experience of stressful life events, in adolescents with conversion disorder, for elucidating the psychodynamics of the disorder. Work attributed to: Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi References 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, First Indian edition. New Delhi: Jaypee Brothers Medical Publishers (p) Ltd; Manchanda M, Manchanda R: Neuroses in children: Epidemiologic aspects. Indian J Psychiatry 1978, 20: Sharma SN, Bhat VK, Sengupta J: Neurosis in children. Indian J Psychiatry 1980, 22: Saxena S, Pachauri R, Wig NN: DSM-III Diagnostic Categories for ICD-9 Hysteria: a study on 103 cases. Indian J Psychiatry 1986, 28(1):

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25 Ishikura R, Tashiro N (2002). Frustration and fulfilment of needs in dissociative and conversion disorders. Psychiatry Clin Neurosci; 56 (4): Lupu V (2005). Cognitive -Behavioral Therapy in the Case of a Teenager with Conversion Disorder with Mixed Presentation. Journal of Cognitive and Behavioral Psychotherapies; 5 (2): Morgan CT, King RA, Weisz JR, Schopler J: Introduction to psychology. Seventh edition. New Delhi: Tata McGraw-Hill publishers; 1993: Sadock BJ, Sadock VA: Somatoform Disorders. In: Synopsis of Psychiatry, 10 th edition. New Delhi: Wolters Kluwer (India) Private limited; 2007: Malhotra S, Varma VK, Varma, SK and Anil Malhotra: Childhood Psychopathology Measurement Schedule: Development and standardization. Indian J Psychiatry 1988, 30 (4): Udai P, Devi RS, Rosenzweig S: The Indian Adaptation of the Rosenzweig Picture-Frustration Study. Second edition. Varanasi: Rupa Psychological centre; Bhatia CM: Bhatia s Battery of Performance Tests of Intelligence. Agra: National Psychological Corporation; Malin AJ: Vineland Social Maturity Scale and Manual Nagpur Adaptation. Lucknow: Indian Psychological Corporation; Dr. Narayana Keertish, Associate Professor, Department of Psychiatry, BGS Global Institute of Medical Sciences, Bangalore. Dr. Indira Sharma, Professor and Head of Department and Head of Child and Adolescent Psychiatry Unit, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi.