Conversion and dissociation

At the start of the First World War the conditions that we now call conversion and dissociative disorders were common. They were largely thought to occur in women, although similar symptoms were recognized in males. At that time conversion disorders were understood to be conditions in which a psychological conflict occurred to which the patient could not consciously admit. According to Freud, there was at least one motive which could be allowed to emerge into consciousness. For example, a woman may develop hysterical symptoms because a forbidden Oedipal wish—to be closer to a man who, to her, represents her father—is in conflict with unconscious feelings of guilt that she is thereby displacing her mother in such a relationship. The resolution of both these unconscious wishes with a symptom like a paralysis which prevented a man from courting her would constitute the primary gain of her illness. This notion of primary gain is basic to the Freudian dynamic theory. It should not be confused with secondary gain which is more often mentioned and which represents the advantages that follow from the sick role (e.g. the loss of the use of a limb), with such benefits as extra attention, nursing, special consideration, and perhaps financial reward in compensation cases. According to this theory, secondary gain is an important part of the reinforcing mechanisms in the maintenance of hysterical symptoms—a rather common-sense idea. However, primary gain is part of the causal system.

The original Freudian theory suggested that ideas which were completely absent from the patient's memory in a normal state, or present only in 'a highly summary form', could be revealed by hypnosis. These memories were held to be related to psychic traumas which had not been disposed of either by abreaction (i.e. purging and discharge of emotion) or by normal associative wearing away in consciousness. The abnormal state was supposed to be produced because of either the strength of the undischarged feelings (affect) attaching to the trauma or a constitutional disposition to hypnoid states. According to this theory the unconscious feeling is in some way converted into the physical symptom. Freud first thought that in certain cases this was a chemical process or failure to discharge energy, for example anxiety following coitus interruptus. However, in Freud's theories the word conversion has since come to represent psychological energy rather than a specific physical change.

The word 'conversion' is conventionally applied to somatic symptoms produced in the above fashion or to somatic symptoms which have a pattern due to an idea. If the symptom is psychological (e.g. a loss of memory or an external hallucination) rather than bodily (e.g. a loss of power or the presence of pain), it is regarded as dissociative. Theoretically, both psychological and bodily complaints have the same ultimate origin, and ICD-10 (.!3> describes conversion and dissociative disorders in a rather similar way. All conversion symptoms are by definition also dissociative and, as explained below, the relevant section in ICD-10 is entitled 'F44 Dissociative (conversion) disorders'.

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Pregnancy And Childbirth

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