Psychological Non Epileptic Seizures
Northeast Regional Epilepsy Group

Recent article: Conversion disorder and the trouble with trauma

 

Kanaan and Craig recently published an article “Conversion disorders and the trouble with trauma” (see reference at the bottom of this page) in which they present the reader with a cogent overview of the current debate of whether conversion disorder should be conceptualized as “psychogenic” or instead “as a yet unexplained neurological disorder.” They argue, quite persuasively that what might seem like an academic discussion in semantics and theory, has the potential for substantial effects on those living with conversion disorders (CD) in general and psychogenic non-epileptic seizures (PNES).

Those who support the “as yet unexplained neurological basis” claim that many patients prefer a nomenclature and etiology that are far removed from “psych” factors because this reduces the stigmatization associated to “psych.” Although I might argue that we should maybe aim to counter the uninformed attitudes that lead to the stigmatization of “all that is psych” rather than renaming conditions and trying to obscure their associated or underlying psychological factors (but let’s leave this for another day, another discussion).  They also state that there remains limited or unclear evidence for a psychological cause in all cases of CDs.

Tracing some of the history of CDs (which have already before been presented “as yet of unexplained neurological basis”-see Charcot for example with his “dynamic lesions”), Kanaan and Craig call attention to the dangers of divorcing CDs from the “psychological,” from the life adversities, traumas, stress that may play a key role in the development and maintenance of conversion (functional) symptoms. The danger is that if/when the neuropathological basis for CDs again fails to be discovered by scientists, CDs might yet again be reclassified as malingered symptomatology. The authors argue that this could be a catastrophic reversal for these patients from where we are now.

The authors discuss the theory that CDs are caused by an experience, one that may not appear objectively traumatic, may not be recognized as causal by the patient her/himself, or may not be immediately temporally associated with the onset of the symptoms. It is tremendously difficult to prove this theory because how is “preceding” defined, how is a “stressor” defined?

Kanaan and Craig’s article then appreciably compares and contrasts post traumatic stress disorder (PTSD) from CDs. A particular difference is that in PTSD, there is/are “obvious stressor/s” that the patient can clearly identify, while in CD, the patient may not identify their stressors or the emotions associated to them (alexithymia) or may have experienced a multiplicity of small stressors (disappointments, humiliations, etc.) over time that have affected the patient–Francine Shapiro’s concept of the “small t” trauma versus the “large T” trauma might be useful concepts here. However, the potential impact of these “small ts” is incredibly hard to evaluate in patients who present with alexithymia and somatization and avoidance tendencies!

Kanaan and Craig conclude their compelling article discussing their thoughts on future research and the role trauma will possibly play in all of this.

If you are a clinician with an interest in PNES and have a chance to get your hands on this article, do it. It will leave you thinking and wanting to tackle these issues.

 

Reference: Kanaan RAA, Craig TKJ (2019). Conversion disorder and the trouble with trauma. Psycholog ical Medicine 1–4. https://doi.org/10.1017/S003329171900099

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