Conversion disorder

Incest is the most common form of child sexual abuse and is a violation of the child's physical, emotional, psychological, and spiritual self (1) It is ". . . the sexual exploitation of a child by another person in the family, who stands toward them in a parental role, or in a relationship invested with significant intimacy and authority."(2) Researchers estimate that more than one in five women are adult incest survivors.(3) There are wide-ranging sequelae to the incest experience, which often serve to motivate survivors to present themselves to physicians (Table 1 (4-7). Gelinas indicates that incest victims often have a disguised presentation that is characterized by a "depression with complications and atypical impulsive and dissociative elements."(4)

Because of the pervasiveness of incest, family physicians will undoubtedly be involved with patients who are incest survivors. As most patients do not directly reveal or disclose these histories,(8-9) physicians must learn how to read the disguised presentation of these individuals if they are to help them acquire the treatment that they need. Furthermore, since incest survivors may overuse medical services as a result of somataform symptoms, (10) it behooves the family physician to learn how to identify these patients and refer them for appropriate treatment. Case Report A 22-year-old single woman with low-average intelligence was referred for psychological evaluation. She had been seen the week before by a resident in a Family Practice Center where she complained of continuous belching for the past 24 hours. She gave a history of having experienced similar belching episodes over the past 2 1/2 years. On one occasion, the belching was so severe that she made a visit to an emergency department, where she was treated with diazepam. Other than sporadic bouts of uncontrollable belching, the patient had no other complaints.

The resident believed that the patient's mental status examination was within normal limits and physical examination findings were negative. The resident noted that upon close observation the patient appeared to be swallowing air and then quickly expelling it. It was noted that the patient did not belch while talking or when inhaling deeply for auscultation of her lungs.

The patient was informed by the resident that he believed her problem was due to swallowing air, an action which was driven by unknown psychological reasons. She was given the diagnosis of acrophagia, possibly secondary to conversion disorder, and was scheduled to see a psychologist for further evaluation.

In the meeting with the psychologist, the patient indicated that she did not know why she was belching and did not appear to be very concerned about her symptoms. She did indicate that the belching had begun approximately 2 1/2 years ago and was brought on suddenly by stress or by eating certain types of acidic foods. She indicated that she required treatment in an emergency department after she began nonstop belching at a family reunion the previous year. She related that the belching is frequently accompanied by what she described as "something like phlegm that keeps wanting to come up."

Family history revealed that her parents divorced when she was 7 years old, and that her father had been very abusive to her mother and had frequent extramarital affairs. On one occasion, prior to her parents' divorce, the patient had witnessed hecr father chasing her maternal grandmother around the house with a gun, threatening to kill the grandmother because she was threatening to expose his extramarital affairs.

The patient stated that her grandmother recently told her that as a child the patient would develop "asthmatic attacks" whenever she went to her father's house for visitation after her parents' divorce. The patient was told that on one occasion the attack was severe enough to require a trip to an emergency department. The patient also reported that she did not remember much of her childhood, although she vaguely remembered a visit to her father's home when she was 8 years old during which he locked her in the bedroom with him. She stated that she did not remember what happened in the room but that she does remember her sister (who was 6 years old at the time) crying hysterically to let her into the room with them. Upon arriving home from this incident, the young woman stated that her mother and grandmother both questioned her about "the room" but that she could remember nothing and then passed out as her mother md grandmother proceeded to question her. When asked why the asthmatic attacks were triggered at her father's home, she replied that they were "probably due to being allergic to his guinea pig."

The patient's grandmother, who had brought her to the psychologist, was asked about the possibility of sexual or physical abuse in the patient's past, as this often potentiates symptoms such as those the patient was experiencing. The grandmother immediately looked at the patient and said, "you better tell her." The patient hung her head, at which point the grandmother indicated that it was exactly 1 week ago, immediately after seeing the resident physician, that the patient told her that "daddy did things to me when I was little and he said he would shoot you if I told."

One week before, for the first time, the patient had revealed an incestuous relationship with her father that included fellatio. The grandmother tearfully reported that as a child the patient had always "gotten sick" whenever she visited her father and would have "blackout spells" and asthma attacks upon returning from the visits. The grandmother also stated that as a child, the patient frequently had nightmares and would "thrash about in the bed worse than you can imagine" when she was sleeping. the grandmother concluded by stating that the patient's symptoms always "puzzled" physicians and her family.

The patient was started in weekly 1-hour psychotherapy sessions. The grandmother was included for part of each session because she was the patient's primary source of emotional support. The focus of the first few sessions was on allowing the patient to break the secrecy of her past by discussing her early incestuous experience. In tandem with allowing the patient to discuss her abuse, work was done with the patient regarding how she frequently doubted the authenticity of her own memories. (This is a common phenomenon for individuals who are in the early stages of treatment.) Time was also spent helping this woman learn how to express her anger.

Currently, the patient reports a great reduction in her uncontrollable belching; this has been corroborated by the grandmother. Unfortunately, as this particular symptom diminishes, and as the sessions continue to examine her incest experience, she is showing signs of clinical depression. Discussion This is a case of the development of an acrophagia conversion disorder in a young woman with a previously undisclosed history of incest. The essential feature of a conversion disorder is an "alteration or loss of physical functioning that suggests physical disorder but that instead is apparently an expression of a psychological conflict or need."(11) Other diagnostic criteria are described in Table 2.(11)

Conversion symptoms serve as a defense mechanism to keep an internal conflict, drive, or past trauma out of one's conscious awareness.(11) In other words, by focusing on the physical symptom, the patient does not have sufficient energy left to have his or her inner secrets or memories revealed. In the case reported here, the patient, by focusing on her belching, was not likely to spend time thinking about her childhood trauma. It is important to note that these symptoms first developed when she began dating. One interpretation was that with the onset of dating she opened the door to possible sexual activity. Many incest victims are threatened by the prospect of sexual activity(12) even in nonabusive relationships) and often begin remembering prior episodes of previously repressed abuse once dating begins. For the patient, belching was an ingeniously functional way to distract herself from the threat of remembering her past abuse.

A paradoxical role that conversion symptoms play, especially with regard to incest victims, is that of forcing the victim to deal with her past trauma if the wounds to her psyche arc to heal. While the conversion symptom itself demands much specific attention, its presence also demands that the prior history of abuse be disclosed and reckoned with if the symptom is to abate. In other words, the symptom is a constant reminder of the unexamined secret of the past. The conversion symptom is a nonverbal communication in body language whose function is to compel the victim to deal with the abuse.

The literature reports cases of conversion symptoms in the form of gagging and swallowing problems in incest survivors who were forced to perform oral sex.(6) In this case the belching accompanied by a substance "......something like phlegm that keeps wanting to come up" was a metaphor for her abuse. The belching symbolized her disgust and revulsion with what happened to her. the meaning of a "phlegmlike substance" to this young woman who later revealed that as a child she had been forced to perform fellatio on her father is also easily understood.

In summary, this case illustrates the role of conversion symptoms in an incest victim. A symptom of belching was unconsciously created by the patient to both protect herself from the reality of sexual abuse and at the same time confront the reality of her abuse. This symptom eventually forced her to seek a physician who was able to recognize that her symptom had some undisclosed meaning and needed psychological evaluation. Thus, the young woman found herself in a position to begin dealing with her past trauma. As this case illustrates, it is of great importance that physicians appreciate and respond to the significance of the relationship between conversion disorders and the possibility of unresolved childhood incest histories.

Key words. Incest; conversion disorder; eructation. References 1. Milford R. Management of sexual abuse: a general practice perspective.

N Z Fam Phys 1990; Winter:119-21. 2. Kluft R. Introduction. In: Kluft R, ed. Incest-related syndromes of

adult psychopathology. Washington, DC: American Psychiatric

Press, 1990:1-10. 3. Russell D. The secret trauma: incest in the lives of girls and

women. New York: Basic Books, 1986. 4. Gelinas D. The persisting negative effects of incest. Psychiatry

1983; 46, 313-32. 5. Lees S. Cues to identifying women with histories of incest. Cambridge,

Mass: Incest Resources, 1981. 6. Courtois C, Sprei J. Retrospective incest therapy for women. in:

Walker L, ed. Handbook on sexual abuse of children. New York:

Springer, 1988:270-08. 7. Drossman D, Leserman J, Nachman G, et al. Sexual and physical

abuse in women with functional or organic gastrointestinal disorders.

Ann Intern Med 1990; 113:828-33. 8. Herman J. Father-daughter incest. Cambridge, Mass: Harvard

University Press, 1981. 9. Summit k. The child sexual abuse accommodation syndrome.

Child Abuse Negl 1983; 7:177-93. 10. Walker E, Katon W, Harrop-Griffiths J, et al. Relationship of

chronic pelvic pain to psychiatric diagnoses and childhood sexual

abuse. Am J Psychiatry 1988; 145:75-80. 11. American Psychiatric Association. Diagnostic and statistical manual

of mental disorders. 3rd cd. Washington, DC: American Psychiatric

Association, 1987. 12. Finkethor D. Child sexual abuse: new theory and research. New

York: Free Press. 1984. Submitted April 3, 1991. From he Family Practice Residency Program, Barberton Citizens Hospital, Barberton, Ohio. Requests for reprints should be addressed to Marybeth Hendricks-Matthews, PhD, Director of Behavioral Science, Family Practice Residency Program, 155 Fifth St., N-E., Barberton, Ohio 44203. [C] 1991 Appleton & Lange ISSN 0094-3509

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