CONVERSION DISORDER CONSISTS of one or. Childhood emotional abuse and dissociation in patients with conversion symptomspcn_

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1 Psychiatry and Clinical Neurosciences 2009; 63: doi: /j x Regular Article Childhood emotional abuse and dissociation in patients with conversion symptomspcn_ Vedat Sar, MD,* Serkan Islam, MD and Erdinç Öztürk, PhD Clinical Psychotherapy Unit and Dissociative Disorders Program, Department of Psychiatry, Medical Faculty of Istanbul, University of Istanbul, Istanbul, Turkey Aim: The aim of the present study was to evaluate the relationship between reported childhood trauma and dissociation in patients who have a conversion symptom. Method: Thirty-two outpatients with a conversion symptom were evaluated using Dissociative Experiences Scale, Somatoform Dissociation Questionnaire, Childhood Trauma Questionnaire, Spielberger Trait Anxiety Inventory, Clinician-Administered Dissociative State Scale, and Dissociative Disorders Interview Schedule. Results: A DSM-IV dissociative disorder was diagnosed in 46.9% of the patients. Conversion patients with a dissociative disorder had borderline personality disorder more frequently than those without a dissociative disorder. Among childhood trauma types, emotional abuse was the only significant predictor of dissociation in regression analysis. None of the childhood trauma types predicted borderline personality disorder criteria. Conclusions: Borderline personality disorder, dissociation and reports of childhood emotional abuse refer to a subgroup among patients with conversion symptom. Dissociation seems to be a mediator between childhood trauma and borderline phenomena among these patients. Key words: borderline personality disorder, conversion, dissociation, somatization, trauma. CONVERSION DISORDER CONSISTS of one or more physical (usually pseudoneurological) symptoms that cannot be explained by any medical disorder. 1 Suggestive of high psychiatric comorbidity, patients with conversion disorder have overall psychiatric symptom scores close to those of general psychiatric patients. 2 Accordingly, in a primary health-care center, conversion symptoms were more frequently observed among subjects who had an ICD-10 diagnosis. 3,4 Depression, generalized anxiety disorder, and neurasthenia were the most prevalent psychiatric disorders among them. In terms of DSM- IV, beside being a disorder on its own, conversion *Correspondence: Vedat Sar, MD, Istanbul Tip Fakültesi Psikiyatri Klinigi, Capa, Istanbul, Turkey. vsar@istanbul.edu.tr. Received 2 October 2008; revised 30 May 2009; accepted 5 June symptoms may also happen as part of somatization disorder or a chronic complex dissociative disorder such as dissociative identity disorder. 5 8 Conversion symptoms are observed both in psychiatric and general medical settings in Turkey quite frequently. Among outpatients who were admitted to a primary health-care institution in a semi-rural area in Turkey, the prevalence of conversion symptoms in the preceding month was 27.2%. 3 The lifetime rate increased to 48.2%. A recent epidemiological study conducted in a representative sample of women in the general population from a non-industrialized region in Turkey yielded a lifetime prevalence of 48.7% for conversion symptoms. 8 In a further study conducted in both genders using a different methodology including a screening for attribution of the symptoms to an immediate stressful life event, 5.6% of the participants had a DSM-IV conversion disorder. 9 Recent reports from Western Europe and North 670

2 Psychiatry and Clinical Neurosciences 2009; 63: Child abuse, dissociation, and conversion 671 America also underline that conversion symptoms are widely prevalent in general medical settings such as neurology departments. 2,10,11 Due to the high number of laboratory and clinical examinations required for differential diagnosis, financial burden of pseudoneurological conversion symptoms may be of considerable scope. Conversion disorder is linked historically to the concept of hysteria. Toward the end of the 19th century, Pierre Janet conceptualized hysteria as a dissociative disorder related to psychologically traumatic life experiences and described somatoform symptoms as aspects of this condition. 12 Although Janet s contemporary, Sigmund Freud, also considered hysteria to be a trauma-based disorder initially, he later conceptualized these somatoform symptoms as the result of a psychological defense mechanism and referred to them as conversion symptoms. 13 Although the DSM-III and its subsequent versions have considered dissociative and conversion disorders as separate groups, latest version of the International Classification of Diseases, the ICD-10, classified both manifestations under the rubric of dissociative disorders. 4,14 This is in accordance with the findings of recent studies that have delivered evidence for the relationship between somatoform symptoms and dissociation. 2,15,16 Several authors have suggested the consideration of conversion disorder as a dissociative disorder in psychiatric classifications. 1,17 Interestingly, high sexual abuse rates have been found for pseudoseizures, 10 somatization disorder, 18 and conversion disorder patients in general. 4,8,19 Both somatoform and psychoform dissociation are correlated with reported childhood trauma Of dissociative disorder patients in Turkey, 46.0% reported childhood physical abuse and 33.0% reported childhood sexual abuse. 24 Sexual abuse and dissociation are independently associated with several indicators of mental health disturbance, including risk-taking behavior such as suicidality, self-mutilation, and sexual aggression. 25 Thus, not only a wide overlap between conversion and dissociative disorders, but childhood trauma reports have also been documented as a common feature of both disorders. The present study attempted to assess childhood trauma reports and dissociative experiences in patients with conversion symptoms. In order to investigate a possible role of dissociation in the overall characteristics of the psychopathology, we compared conversion patients who had a DSM-IV dissociative disorder with those who did not. METHODS Participants Thirty-two patients admitted for the first time to the psychiatric outpatient unit of the Istanbul University Istanbul Medical Faculty Hospital in a 3-month period (1 January 31 March 2006) who had a conversion symptom as the main complaint and were referred by their attending physicians to the study group participated in the study. A total of 70.6% (n = 23) had pseudoseizures. Three patients had gait disturbance and two had paresthesia. Symptoms of the four remaining patients were paralysis, inability to speak, and blurred or double sight. An earlier screening study conducted on a consecutive series of patients showed that pseudoseizure was the most frequent conversion symptom in clinical settings in Turkey; 26 thus, the symptom composition of the patient group evaluated in the present study does not deviate from general observations in that country. The patients were between 18 and 65 years of age, and the average age of the probands was years. Twenty-seven of them were women and five were men. There was no significant difference in age between male (mean age, years and female subjects (mean age, years; t = 0.19, d.f. = 30, P = 0.853). The patients had years of education on average. The patients provided written informed consent for participation after the study procedures had been fully explained. All interviews were conducted by the same psychiatry resident. The interviewer had extensive experience in administration of the instruments. Assessment instruments The Dissociative Disorders Interview Schedule is a structured clinical interview consisting of 131 items. It was designed by Ross et al. to diagnose somatization, major depression, borderline personality disorder and five classes of dissociative disorders according to the DSM-IV. 27 The schedule also inquires about childhood abuse and neglect and a variety of features associated with dissociative identity disorder, including 11 Schneiderian symptoms, 16 secondary features of dissociative identity disorder, and 16

3 672 V. Sar et al. Psychiatry and Clinical Neurosciences 2009; 63: extrasensory experiences. The validity and reliability of the Turkish version have been reported elsewhere. 28 The Dissociative Experiences Scale (DES) is a 28-item self-report instrument developed by Bernstein and Putnam. 29 It is not a diagnostic tool but serves as a screening device for chronic dissociative disorders, with possible scores ranging from 0 to 100. The Turkish version of the scale has good reliability and validity. 30 In Turkey, a cut-off score of 30 has been shown to be useful in screening dissociative disorders among general psychiatric patients. 28 There is also a taxon form of the scale (DES-T), which consists of an eight-item subset that are inherently pathological. Taxometric analysis of these items yields a high probability that an individual is in one of two discrete categories: normal, or suffering from pathological dissociation. 31 The Somatoform Dissociation Questionnaire (SDQ) is a 20-item self-report instrument that evaluates the severity of somatoform dissociation. The SDQ was developed by Nijenhuis et al. 16 The Turkish version of the scale has a 1-month test retest correlation of A cut-off of 35 yielded a sensitivity of 0.84 and a specificity of 0.87 for dissociative disorder diagnosis in a Turkish clinical sample. 24 The Clinician-Administered Dissociative State Scale (CADSS) is a 27 item scale with 19 subject-rated items and eight items scored by an observer. 32 It has a high level of interrater reliability, with an intraclass correlation coefficient (ICC) of 0.92 for the total score, and ICC of 0.99 for the subject-rated subscale. There was a more modest level of agreement (ICC = 0.34), for the observer-rated component. The Spielberger State-Trait Anxiety Scale (STAI) is a 40-item self-report instrument. 33 Participants indicate their agreement with each item on a Likert scale ranging from 1, not at all, to 4, very much so. The STAI has good reliability and validity. The Childhood Trauma Questionnaire (CTQ) is a 28-item self-report instrument developed by Bernstein et al. that evaluates childhood emotional, physical, and sexual abuse and childhood physical and emotional neglect. 34 Possible scores for each type of childhood trauma range from 5 to 25. The sum of the scores derived from each trauma type provides the total score ranging from 25 to 125. A study using the Turkish version of the scale on 80 patients with drug dependency, 22 patients with borderline personality disorder, and 90 non-clinical controls demonstrated good reliability and validity. 35 A separate test retest study conducted by the first author of the present study on 48 clinical and non-clinical subjects at an interval of 2 weeks yielded a high correlation for the CTQ-28 total score (r = 0.90 P = 0.001). Correlations were significant at a high significance level (P = 0.001) for emotional abuse (r = 0.90), emotional neglect (r = 0.85), physical abuse (r = 0.90), sexual abuse (r = 0.73), and physical neglect (r = 0.77) as well. The scale has been used successfully in several previous studies with consistent results in Turkey, including subjects with conversion disorder, 7 borderline personality disorder, 36 dissociative disorders, 37 and schizophrenia. 38 Statistical analyses Frequency and percentage were used for sociodemographic variables. c 2 statistics (Fisher exact test where appropriate) was used for comparison of patients on categorical variables. Mann Whitney U-test was used to compare the dissociative and nondissociative groups on continuously distributed variables. Linear regression analyses were performed to determine predictors of dissociative experiences and borderline personality disorder criteria. For all statistical analyses the level of significance was set at P < RESULTS Fifteen patients (46.9%) had a DSM-IV dissociative disorder on structured diagnostic evaluation. Nine patients (28.1%) had depersonalization disorder, eight patients (25.0%) had dissociative disorder not otherwise specified (DDNOS), seven patients (21.9%) had dissociative amnesia, three (9.4%) had dissociative fugue, and two (6.2%) had dissociative identity disorder. Two DDNOS patients had mild forms of dissociative identity disorder, that is, they had distinct personality states without fully meeting diagnostic criteria of the latter. Two of the remaining DDNOS patients had a combination of dissociative amnesia and derealization, and four had trance episodes. Eight patients (25.0%) with a conversion symptom had a DES score 30, and 14 patients (43.8%) had an SDQ score 35.0, which have been determined as cut-off scores for screening of a DSM-IV dissociative disorder in previous studies on Turkish patients. 24,29,32,33 There was no significant difference between patients with and without a dissociative disorder with

4 Psychiatry and Clinical Neurosciences 2009; 63: Child abuse, dissociation, and conversion 673 Table 1. Scale scores and mental health features among conversion disorder patients Sociodemographic and mental health items Dissociative disorder present (n = 15) Dissociative disorder absent (n = 17) Total (n = 32) Mean SD Mean SD Mean SD Z P Mann Whitney U-test Age Education (years) Extrasensory experiences Secondary symptoms of dissociative identity disorder Borderline personality disorder criteria Somatic symptoms Schneiderian symptoms Dissociative experiences scale score Childhood trauma questionnaire total score Emotional abuse Emotional neglect Physical neglect Sexual abuse Physical abuse Minimization of trauma Somatoform dissociation questionnaire total score CADSS STAI CADSS, Clinician-Administered Dissociative State Scale; STAI, Spielberger Trait Anxiety Inventory. regard to age and gender (Tables 1,2). SDQ, CADSS and STAI scores did not differ between the two groups, but the dissociative disorder group had higher DES scores on average. There was no difference in scores of any childhood trauma type, nor in total CTQ scores (Table 1). Beside secondary symptoms of dissociative identity disorder, patients with dissociative disorder endorsed higher numbers of borderline personality disorder criteria and extrasensory experiences on average. They had borderline personality disorder diagnosis and DES taxon membership more frequently than the non-dissociative group. There was no difference in major depression and somatization disorder comorbidity and frequency of various childhood trauma types between the two groups (Table 2). Table 3 lists results of three stepwise linear regression analyses in which DES, SDQ, and CADSS scores were used as dependent variables, while the five childhood trauma subscores of CTQ were entered as independent variables. Only childhood emotional abuse predicted DES and SDQ scores. CADSS scores were predicted both by emotional abuse and neglect. A linear regression analysis taking the total number of endorsed borderline personality disorder criteria as a dependent variable and five types of childhood abuse and neglect as predictors yielded no significant results (F = 0.62; adjusted R 2 =-0.07; d.f. = 5,31; P = 0.688). DISCUSSION According to the structured diagnostic evaluation, a sizeable proportion of patients with a conversion symptom (46.9%) had a DSM-IV dissociative disorder in the present study. The patients endorsed DES (mean, 19.2) and SDQ scores (mean, 35.5) lower than those of the dissociative disorder patients in Turkey (49.1 and 52.5, respectively). 24,39 These scores, however, are markedly above the means for Turkish non-clinical populations: 11.8 and 27.4, respectively. 24,40 Overall, the comparison between subjects with and without a dissociative disorder demonstrated that dissociation is an indicator of a more chronic and severe psychiatric condition. The rates of reported childhood emotional (53.1%) and sexual abuse (9.4%) in the present study were much higher than those obtained in an epidemiological study among women from the general population in Sivas, Turkey, using the

5 674 V. Sar et al. Psychiatry and Clinical Neurosciences 2009; 63: Table 2. Mental health history and psychiatric comorbidity among conversion disorder patients Dissociative disorder present n = 15 Dissociative disorder absent n = 17 Overall n = 32 Mental health history items n % n % n % c 2 (d.f. = 1) P Gender (women) Fisher s exact test DES taxon membership Fisher s exact test Borderline personality disorder Major depression (current) Major depression (lifetime) Somatization disorder Childhood emotional abuse Childhood neglect Childhood physical abuse Fisher s exact test Childhood sexual abuse Fisher s exact test Any childhood abuse and/or neglect Fisher s exact test Suicide attempt Fisher s exact test Previous psychiatric treatment Fisher s exact test DES, Dissociative Experiences Scale. same methodology: 10.8% and 2.5%, respectively. 40 Although there was no significant difference between conversion patients with and without a dissociative disorder on any childhood trauma type in the present study, a stepwise multiple regression analysis conducted on quantitative scores demonstrated that emotional abuse had a statistically significant effect on dissociation scores. An earlier study on conversion disorder patients collected from a clinical setting in a less industrialized region of Turkey found the same relationship. 7 A study on subjects with depersonalization disorder in North America demonstrated that emotional abuse is the most significant predictor of depersonalization but not of general dissociation scores, which were better predicted by combined emotional and sexual abuse. 25 Nevertheless, the most frequent dissociative disorder among patients with a conversion symptom in the present study was depersonalization disorder. In contrast, none of the subjects with somatization disorder had depersonalization disorder in an epidemiological study in Turkey. 8 Apparently, patients with conversion and somatization disorder differ in their perceptions about and/or their relationship with their body. 41 A study conducted among women in the general population documented that conversion and somatization disorders differ in severity of psychopathology in terms of higher rates of psychiatric comorbidity and childhood trauma in the latter, including borderline personality disorder. 8 Selfdestructive behavior and childhood trauma are known to be common both in borderline Table 3. Childhood trauma types as predictor of scale scores in stepwise linear regression analysis B adjusted R 2 Standard error b t P Dependent variable: dissociative experiences scale (F = 12.11; df = 31, 1; P = 0.002) Emotional abuse Dependent variable: clinician administered dissociative states scale (F = 11.58; df = 31; 2 P < 0.001) Emotional abuse Emotional neglect Dependent variable: somatoform dissociation questionnaire (F = 7.00; df = 31; 1 P = 0.013) Emotional abuse

6 Psychiatry and Clinical Neurosciences 2009; 63: Child abuse, dissociation, and conversion 675 personality disorder and in dissociative disorders Subjects with borderline personality disorder frequently have dissociative experiences, 47 dissociative disorders 48, and somatization disorder. 37 Chu and Dill argued that borderline personality disorder is a type of post-traumatic syndrome involving the mechanism of dissociation. 20 Nevertheless, a considerable proportion (34.3%) of conversion patients in the present study were diagnosed as having borderline personality disorder, and most of them belonged to the dissociative disorder group. In contrast to dissociation, none of the childhood trauma scores predicted borderline personality disorder criteria on regression analysis. Thus, the relationship between childhood trauma and borderline personality disorder was not a direct one. Notwithstanding the possible contribution of biological and/or genetic vulnerabilities, dissociation seems to be the mediator between childhood trauma and borderline phenomena among this subgroup of conversion patients. According to the structural dissociation model of personality, borderline personality disorder may be explained by trauma-related personality fragmentation, leading to emergence of relatively autonomous (dissociated) self-states and action systems, which take control of executive functions interchangeably. 49,50 Thus, dissociated self states underlie the stable instability of the patients. 51 Proposing a new category of complex posttraumatic stress disorder, van der Kolk et al. 52 demonstrated that post-traumatic stress disorder, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to trauma; they often occur together, but traumatized individuals may suffer various combinations of symptoms over time. Alongside childhood interpersonal trauma, some authors suggest a relationship with attachment styles among patients with pseudoseizures. 53 Underlining the role of interpersonal trauma, a new category of relational trauma disorder has also been proposed for this spectrum of psychopathology. 51 Indeed, as represented by the older concept of Briquet syndrome as well, 54 the wide overlap between conversion disorder, dissociative disorders, and borderline personality disorder alongside dysthymic disorder, major depression, and somatization disorder and the relation of the overall psychopathology to childhood trauma deserves comprehensive understanding and explanation. 55 In the present study, alongside borderline personality disorder criteria and secondary features of dissociative identity disorder, extrasensory perception experiences were common among conversion patients with a dissociative disorder (Table 1). These symptoms cover experiences such as being possessed by jinnies or other outside forces or supernatural experiences such as telepathy and being in contact with spirits. Although these phenomena are known to be more common in non-western cultures, a study conducted in Canada also documented the relationship between extrasensory experiences, childhood trauma and dissociation. 56 The present study had several limitations. First, the study group was small and the procedure of collection of probands did not guarantee a representative sampling. Most of the patients in the study group had pseudoseizures and the gender distribution was overwhelmingly female. Nevertheless, pseudoseizure is the most frequently seen conversion symptom in Turkey, 26 and female patients are usually overrepresented in studies on conversion disorder from Turkey, Western Europe, 2,19 and North America. 11 In an epidemiological study in Turkey, 57 although there was no difference in average dissociation score between genders, twofold more women than men were included among high scorers. Thus, the overrepresentation of women and pseudoseizure patients in the present study does not seem to be a selection bias. A second limitation of the present study was the lack of information about childhood psychiatric disorders for this group of patients. For instance, attentiondeficit hyperactivity disorder has been reported as frequent in borderline personality disorder. 58 Further studies should take this into consideration. As a further limitation, findings of the present study may be culture-specific and should not be generalized until they are supported by similar reports from diverse cultures. Finally, being retrospective in nature, childhood trauma reports are subject to possible reinterpretation and are also susceptible to distortions by psychopathology. We tried to overcome this probability as much as possible, however, by using a standardized assessment instrument. CONCLUSIONS Concurrent dissociation is a clue for more severe psychopathology among patients with conversion symptoms. This subgroup of conversion patients are characterized by a history of emotional abuse and are prone to fit the diagnostic criteria of borderline personality disorder. Dissociation seems to be a media-

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