Introduction

Puberty and teenage is the time of lot of changes that are occurring physically, mentally, psychologically, emotionally and socially. This causes turmoil of feelings in the teenagers. Teenagers are confused and perplexed about all the changes going on in their lives. This is the time when most of us become self-centric and want all of the people around us to shower all their love, affection and attention on us. In doing so most of the teenagers start seeking medical attention even for trivial things as this gives them attention they want from their friends, family and peers.

Sometimes it may be due to attention seeking behaviour but at other times it may also be due to increased apprehension about all the physical changes that are occurring in their body. Teenagers may have vague symptoms such as abdominal pain, headaches, dizziness, syncope, fatigue, sleep problems, and chest pain that appear to have no biologic cause. The basic cause for these symptoms may be apprehension, depression, stress or anxiety. The most common reason for all these presenting symptoms is conversion disorder.

What is conversion disorder?

The most common disorder of adolescence is conversion disorder or conversion reaction. A conversion reaction or disorder is a psychological and physical process in which unpleasant feelings, especially anxiety, depression, and guilt, are communicated through a physical symptom. Physiological symptoms results when anxiety and stress causes the activation of autonomic nervous system, causing tachycardia (increased heart beat), hyperventilation (increased breathing rate) and vasoconstriction (constriction of blood vessels).

Conversion disorder occur when the emotional event is either very stressful or shameful or there is a painful experience for the individual that he or she isn’t able to express it verbally and therefore it is expressed as a physical symptom. Since teenage or puberty is the time when lot of changes are taking place in an individual’s life and teenagers usually become shy and introvert. So sometimes they are not able to share and express their feelings. Due to this the hidden feelings and emotional turmoil is expressed as physical symptoms. It is not controlled by the individual and it occurs unconsciously.

The conversion reaction gives a primary gain to the individual. Primary gain is the degree to which the conversion symptom lessens anxiety, depression, or the unpleasant feelings; it also helps release the adolescent from conflict or an uncomfortable situation. This relaxation and freedom from guilt or uncomfortable situation is called secondary gain.

Secondary gain may intensify the symptoms, especially with increased attention from concerned parents and friends. Adolescents with conversion symptoms tend to have overprotective parents and become increasingly dependent on their parents as the symptom becomes a major focus of concern in the family.

What are the symptoms?

Symptoms usually appear at the time of stress and anxiety and usually have no accompanying biologic cause. Conversion disorder presents itself with wide array of symptoms such as

• Paraesthesia: It is the abnormal sensation of tingling, tickling, pricking or burning of a person’s skin.
• Anaesthesia: It is the complete loss of sensation over a body part or whole of the body. It may or may not be accompanied by complete loss of consciousness.
• Paralysis: It is the loss of ability of movement of a part or complete body.
• Dizziness: It is the loss of orientation, stability and spatial relationships.
• Syncope: Temporary loss of consciousness
• Hyperventilation: Increased breathing rate
• Abdominal pain
• Nausea
• Vomiting

Specific symptoms may also be due to existing or previous illness or modelling of symptoms of a close relative. Conversion symptoms are more common in girls than in boys. Although they occur in patients from all socioeconomic levels, the complexity of the symptom may vary with the sophistication and cognitive level of the patient.

How is it diagnosed?

The symptoms usually do not have a biological cause. The most distinguishing characteristic about symptoms is that they appear usually at the time of stress and anxiety. Another important factor is that these symptoms usually occur in the presence of those people who are important to the concerned individual. The striking feature about the individuals affected by conversion disorder is that they are egocentric, self-centred, emotionally dependent and have an attention seeking behaviour. Conversion reactions are often confused with hypochondriasis. Hypochondriasis is a preoccupation with developing or having a serious illness despite medical reassurance that there is no evidence of disease and becomes more anxious if there is any biologic cause related to the presenting symptoms whereas a person with conversion symptoms feels relieved if an organic cause is considered.

Treatment

• Once the diagnosis is established it is important that the adolescent should be handled very tactfully and carefully. It is the duty of the health care provider that relationship between physical causes of emotional pain and emotional causes of physical pain should be described to the family, using examples such as stress causing an ulcer or making a severe headache worse.
• The patient should be encouraged to understand that the symptom may persist and that at least a short-term goal is to continue normal daily activities. Medication is rarely helpful.
• If the family will accept it, psychological referral is often the best initial step toward psychotherapy. If the family resists psychiatric or psychological referral, the paediatrician may need to begin to deal with some of the emotional factors responsible for the symptom while building rapport with the patient and family.
• The teenager should be encouraged to talk about school, friends, the relationship with the parents, and the stresses of life.
• Discussion of the symptom itself should be minimized; as parents gain insight into the cause of the symptom, they should become less indulgent and facilitate resumption of normal activities.
• If management is successful, the adolescent will gain coping skills and become more independent, while decreasing secondary gain.

If the symptom continues to interfere with daily activities and if the patient and parents feel that no progress is being made, psychological referral is indicated. A psychotherapist experienced in treating adolescents with conversion reactions is in the best position to establish a strong therapeutic relationship with the patient and family.

References

1. Nelson textbook of paediatrics, 19th edition, Kliegman, Stanton, St. Geme, Schor, Behrman. Elsevier publication. ISBN: 978-1-4377-0755-7. Chapter-20
2. Current Pediatric Therapy, 18th edition, Frederic et al, ISBN-13: 978-0-7216-0549-4. Chapter-6