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J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(1):7-31

Original Article

Study of Frustration in Adolescents with Conversion Disorder

Narayana Keertish MD, Indira Sharma MD

Address of correspondence: Dr. Narayana Keertish, No. 619, 2nd Cross, RBI Layout,

7th Phase, J P Nagar, Bangalore-560078. Email: keerthish_shetty@rediffmail.com.

ABSTRACT

BACKGROUND: Conversion disorder has been found to be the most common neurotic

disorder in children and adolescents. The relationship between temperament and

conversion disorder is well documented, but there is dearth of Indian studies directed at

studying the psychosocial and temperamental/ personality factors in adolescents with

conversion disorder.

OBJECTIVE: Aim of the study was to assess the reactions of adolescents with

Conversion Disorder to frustrating situations as measured by the Rosenzweig’s Picture-

Frustration Study.

METHODS: Thirty school going adolescents with Conversion Disorder, diagnosed as

per DSM-IV-TR criteria, and thirty healthy matched controls, comprised the sample.

Patients and controls were assessed by the Rosenzweig’s Picture-Frustration Study.

RESULTS: The patient group was superficially well adjusted, as evident by the Group

Conformity Rating score. However, the patient group was deficient in other areas, both in

the type (higher scores on obstacle dominance) and direction of aggression (lower scores

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on imgression). The patient group also had deficiency in the superego defense patterns

(lower scores on intropunitive deviant and combination of intropunitive deviant and

imgression) and pattern of 3 most frequent responses (higher frequency of extrapeditive

scores).

CONCLUSION: Adolescents with conversion disorder, instead of evading the

frustrating situation, are excessively pre-occupied with the barrier causing frustration.

Thus, efforts to overcome this deficiency should be a part of management of conversion

disorder in adolescents in order to achieve early recovery and to prevent relapse.

KEY WORDS: Conversion Disorder, Adolescents, Frustration

Introduction

Conversion disorder is defined as a deficit of sensory or motor function that cannot be

explained by a medical condition and where psychological factors are judged to be

associated with the symptom or deficit because the initiation or exacerbation of symptom

or deficit is preceded by conflicts or other stressors [1].

Conversion disorder has been found to be the most common neurotic disorder in children

and adolescents [2-6]. Although the incidence and prevalence of conversion disorder is

uncertain, it has been reported to vary from 3%-5% [1,7]. Indian studies have reported

incidence of childhood conversion disorder in up to 31% of inpatient and 14% of

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outpatient samples [8]. Conversion disorder is more often seen in females than in males

[9,10]. Nearly one out of five children will have a behavioural or emotional disorder at

some time in their life [11].

Role of temperamental/personality traits

The relationship between temperament and psychopathology is well documented.

Temperament influences the development and psychopathology in two ways: as a

determinant of psycho-neuro-physiological vulnerability and as a determinant of parent-

child interaction in the form of varying the quantity and quality of care evoked by the

temperament of the child [12]. Children with conversion disorder were found to have low

distractibility [13]. Low distractibility may actually mean low soothability i.e. such

children, temperamentally, take longer to come out of a distressed state and remain in

distress for relatively a longer period in the face of day-to-day distress [14].

Ishikura and Tashiro reviewed 9 patients with dissociative disorder and 10 patients with

conversion disorder and found that the patients of both groups, who encountered troubles

in their lives, were found to have frustrated needs [15]. Their symptoms tended to be

accompanied more often by frustrations regarding a 'need for love' in the dissociative

disorder group and by frustration in the need for 'self-esteem and self-actualization' in the

conversion disorder group.

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Psychological investigation of a teenager girl with conversion disorder with mixed

presentation revealed that she had an IQ of 95, rich expressive language, good social

adaptability, low frustration tolerance, egocentrism, a desire to make a good impression

and to be the centre of attention, high suggestibility and histrionic characteristics [16].

The Freudian concept that personality was determined by a dynamic interplay among the

id, ego and superego, supports the idea that conversion symptoms occur as a result of

inability to repress a conflict between the id and the superego [17]. According to

psychoanalytic theory, conversion disorder is caused by repression of unconscious

intrapsychic conflict and conversion of anxiety into a physical symptom. The conflict is

between the instinctual impulse like aggression or sexuality and the prohibitions against

its expression [18].

It is evident from the above review of literature that the temperamental/personality

factors namely; low distractibility, low activity, low emotionality, low frustration

tolerance and the intrapsychic conflict between the instinctual impulse like aggression

(Id) and the prohibition against its expression (Superego), have been implicated in the

causation of conversion disorder in adolescents. Hence, a systematic study of the

reactions to frustrating situations will not only help in understanding the factors that

influence the psychological milieu of children with conversion disorder, but also aid in

planning effective management and prevention of relapse. The present study was

conceived with the aim of studying the nature of frustration (reactions to frustrating

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situations) in adolescents with conversion disorder by Rosenzweig’s Picture-Frustration

Study.

The research hypothesis (H1) for this study was:

There is no significant difference in the nature of frustration of adolescents with

conversion disorder and normal healthy matched controls, on reactions to frustration by

Rosenzweig’s Picture-Frustration Study.

Methods

Sample

The patient group comprised 30 patients in the age group of 12 to 18 years, diagnosed to

be suffering from conversion disorder as per criteria laid down in DSM-IV-TR

(American Psychiatric Association, 2000), who attended the outpatient psychiatry section

(adult and child) of the University Hospital, Banaras Hindu University, Varanasi, India,

Varanasi from March 2008 to July 2009. Patients with co-morbid psychiatric illness or

major general medical condition, Intelligence Quotient (IQ)/ SQ (Social Quotient) of less

than 70 and those not going to school were excluded from the study.

The control group comprised an equal number of apparently healthy children and

adolescents matched with the patient group on age, sex, socio-economic status, domicile

and educational status. Children and adolescents with a score of 10 or more on the

Childhood Psychopathology Measurement Schedule [19], IQ/ SQ of less than 70 and

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those not going to school were excluded from the study. Consent was taken from parents

/guardian and children from both the groups to participate in the study.

The Indian adaptation of the Rosenzweig Picture Frustration study [20] was used to study

the nature of frustration in adolescents with conversion disorder. The Rosenzweig

Picture- Frustration study is a controlled projective technique, primarily intended to

measure reactions to frustrating situations. It was developed as a result of experiments

with repression and frustration carried out by Rosenzweig [20].

The Rosenzweig Picture-Frustration study was adapted and standardized for use in India

by Udai and co-workers [20]. While preparing the Indian adaptation, care was taken to

retain the original situations with as little modification as necessary to make the situations

acceptable in the Indian culture. It is intended for use with adults, but can be used with

adolescents also. The scoring reliability was quite high, the percentage of agreement

increasing to 98% after discussions [20]. Stability co-efficients ranged from 0.27 to 0.82

and consistency values from 0.46 to 0.74.

Methodology

Each patient was assessed in detail on a structured proforma which had items related to

socio-demographic data, psychiatric history, and physical and mental status examination.

IQs/ SQs of the adolescents were assessed with Bhatia Battery of intelligence [21] or

Vineland Social Maturity Scale [22].

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Each patient and control was assessed by the Indian adaptation of the Rosenzweig

Picture-Frustration study. The study consists of 24 cartoon like drawings representing

frustrating situations. In each of the pictures 2 people are shown talking. The words said

by one person are given. The subject is required to imagine what the other person in the

picture would answer in that situation. The very first reply that comes into the mind is to

be told or written. The subject is to work as fast as he can.

General principles of the study

It is assumed as a basis for P-F study that the subject unconsciously or consciously

identifies himself with the frustrated individual in each pictured situation and projects his

own bias in the replies given. Scores are assigned to each response as to the direction and

type of aggression.

Directions of aggression

Directions of aggression included are:

1) Extragression or E-A- in which the aggression is turned on the environment

2) Introgression or I-A- in which it is turned by the subject upon himself;

3) Imgression or M-A- in which aggression is evaded in an attempt to gloss over the

frustration.

Types of aggression

Types of aggression included are:

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1) Obstacle Dominance or O-D- in which the barrier occasioning the frustration stands

out in the responses

2) Ego Defence or E-D- in which the ego of the subject predominates

3) Need Persistence or N-P- in which the solution of the frustrating problem is

emphasized.

Group Conformity Rating (GCR) is a measure of conformity of an individual score to the

modal responses of his group. It may be regarded as “one measure of the individual’s

adjustment to a normal group.” The total E-D score may be said to represent strength or

weakness of the ego, while the N-P score may show adaptive adequacy.

Super ego factors and patterns

Superego (S-E) patterns were calculated to provide a measure of a subject’s

“defensiveness”. The superego deviants E and I were considered in relation with factors

E and I and the category M-A. E is a variant of extrapunitive (E) in which the subject

aggressively denies that he is responsible for some offense with which he is charged. I is

a variant of intropunitive (I) in which the subject admits his guilt, but denies any essential

fault by referring to unavoidable circumstances. M-A (Imgression) refers to evasion of

aggression in an attempt to gloss over the frustration.

Trends

Trends are change of response types with recognizable consistency to any other mode,

and even to change back again or to some third kind of behaviour before reaching the

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end. The formula for calculating the value of the trend is (a-b)/ (a+b), in which ‘a’ is the

amount of factor in the first half of the test and ‘b’ is the amount of factor in the second

half. The total number of possible trends is 15, of which each may be positive or

negative.

1) E’, I’, M’

2) E, I, M

3) e, i, m

4) E-A, I-A, M-A

5) O-D, E-D, N-P

Trends which were not significant as per the significance table given in the manual were

reported as ‘None’.

Total Pattern

In calculating the total pattern, the three factors occurring most frequently, regardless of

the type or direction of aggression, were entered in the order of their frequency and

related to each other by symbols greater (>), lesser (<) or equal (=). Subsequently, the

frequency of the three most commonly occurring factors were tabulated separately for the

control and the patient group.

Comparisons were undertaken on the nature of frustration on the Rosenzweig’s study

between the adolescents with conversion disorder and the control subjects. Chi-square

and Independent samples student t tests were used for the statistical analysis.

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Results

I. Sample characteristics:

Majority of patients were females and Hindus with rural background. All of them

were unmarried and educated. Due to rapid economic growth in recent past, it was

considered appropriate to classify socio-economic status (SES) based on per-capita

income. About half of the patients hailed from low and low middle SES. The

remaining patients were from higher SE strata. There was no significant difference

between the patient and the control groups on sex, domicile, marital status, religion

and SES (table 1A).

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There was no significant difference between the patient and control groups with

regard to age and years of schooling (table 1B).

II. Clinical characteristics of the patient group:

The mean age of onset of illness was 15.05 (range = 9-18) years. Patient group had a

mean duration of illness of 32.92 (range= 1-260) weeks. 93.3% (N=28) presented as

pseudoseizures, 3.3% (N=1) with gait abnormality and 3.3% (N=1) with mixed

presentation). Major life events occurring in the 4 weeks period preceding the illness

were considered as precipitating factors. Precipitating factors were observed in 56.6%

(N=17) of the patients.

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III. Comparison of patient and control groups on Rosenzweig’s Picture-Frustration

Study:

Group conformity rating

The mean Group conformity rating (GCR) of the patient group, was modestly high

(mean 61.67 ± 11.13; Range = 42-79). It did not differ significantly from the control

group (table 2).

Direction of Aggression

The mean imgression score of the patient group was found to be significantly lower

than that of the control group (p=0.021). There was no significant difference between

the patient and the control groups on the mean extraggression and introgression

scores (table 2).

Type of Aggression

The mean obstacle dominance score of the patient group was significantly higher than

that of the control group (P=0.023). There was no significant difference between the

mean ego defence and the mean need persistence scores of the patient and control

groups (table 2).

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Compared to the control group, the patient group had a significantly lower mean

values for the super-ego factors/ patterns, I (p=0.033), E + I (p=0.027), and M-A + I

(p=0.003) (table 3).

Trends

In majority of the patients [19 (63%)-30 (100%)], one or more of the trends were

absent ie None. There was no significant difference (p>0.05) between the patient and

the control group on presence of positive (EA & MA) and negative (E, IA, MA, OD

and ED) trends (Table 4), The frequency of other trends was low and did not permit

statistical comparison.

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Total Pattern

It may be noted that 2 or more than 2 factors amongst the 3 most frequent ones, had

equal frequency in some of the subjects. Therefore, the total number of factors shown

in the table is more than 90. When the total pattern of responses was examined it was

observed that the frequency of E’ (extrapeditive score) was significantly higher in the

patients group than in the control group (0.004). There was no significant difference

between the patient and the control groups with regard to other factors.

Discussion

The present study was a modest attempt to study ‘frustration’ in adolescents with

conversion disorder presenting at the outpatient psychiatry Section of the University

Hospital, Banaras Hindu University, Varanasi. The University Hospital caters to a huge

population hailing from Eastern Uttar Pradesh, Chattisgarh, Jharkhand, Bihar, Madhya

Pradesh and even Nepal.

In the present study, reactions to frustrating situations were assessed with the help of

Rosenzweig’s Picture Frustration Study. The test was administered on an individual basis

because of the opportunity it provided for ‘enquiry’, making scoring and interpretation

more reliable.

Group Conformity Rating (GCR) is the measure of conformity of an individual score to

the modal responses of his group. The patient group had modestly high mean GCR

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(61.67), which did not significantly differ from the mean GCR of the control group,

indicating that on this measure the patient group had an adequate level of adjustment.

The patient and the control groups were compared on the direction of aggression in the

sample. It was observed that patients had significantly lower mean imgression (M-A)

score, compared to that of the control group. The extragression (E-A) and the

introgression (I-A) scores did not differ significantly between the groups. This finding

suggests that the patients did not evade the frustrating situation by attempting to gloss

over it. Instead, they either directed their aggression on to the environment (E-A) or

turned the same upon themselves (I-A). These types of reactions to frustrating situations

are indicative of poor adjustment and coping.

Further analysis was done to explore different types of aggression, namely; obstacle

dominance (OD), ego defence (ED) and Need persistence (NP) in the patient and the

control groups (table . 5). The mean OD score of the patient group was found to be

significantly higher than that of the control group. The mean scores of the ED and NP of

the two groups did not differ significantly. This finding indicates that the patients were

excessively preoccupied with the barrier causing frustration, which may indicate

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‘anxiety’ and embarrassment. The OD scores of the patient group were contributed

predominantly by higher E’ scores in the patient group. Extrapeditive (E’) scores are

given for responses in which presence of the frustrating obstacle is insistently pointed

out.

Super-ego patterns are important as they provide a measure of the subject’s

defensiveness, either in denying the commission of the wrong (E), or in repudiating the

reprehensible motivation connected with such behaviour (I) (Udai & Devi, 2006). The

superego deviants were considered in relation to E (extrapunitive), I (intropunitive) and

the category M-A (imgression). M-A and I were considered together as superego pattern,

as both involved absolution from blame by either excusing someone else or by excusing

oneself.

It was interesting to note that the intropunitive deviant (I) was significantly lower in the

patient group when compared to the control group. The E (extrapunitive deviant),

however, did not differ significantly between the two groups. It follows that the patient

group had weaker superego. While the control group admitted guilt, but denied any

essential fault by referring to unavoidable circumstances, the same pattern was observed

to a much lesser extent in the patient group. When I and E were considered together,

similar findings were observed with patients having lower mean score than the control

group. This was mainly because of the higher mean I score in the controls. Also, patient

group had significantly lower scores compared to the control group when a combination

of M-A and I were considered. This again suggests that superego defences of the patients

are weaker when compared to that of controls.

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As it is possible for subjects to change with recognizable consistency to any other mode,

and even to change back again or to some third kind of behaviour before reaching the

end, the protocols of the patients and controls were analysed for any significant trends.

Five different types of trends, with total 15 trends, each of which could be positive,

negative or none, mentioned in the foregoing chapter, were examined. A positive trend

(←, away from) is one in which a factor/ category predominates in the first half of the

record; the opposite (→, towards) is a negative trend. Trends not significant were

recorded as ‘none’. In the majority of patients, one or more trends were absent i.e. none.

Among the trends found, there was no significant difference when the patient and the

control groups were compared. This finding suggests that by and large, the responses of

the patients to frustrating situations were consistent as no significant difference was

observed between the responses in the first half of the test compared to the second half of

the Rosenzweig’s Picture-Frustration Study.

The total pattern of responses is significant as it provides information on the three most

frequent responses seen in the subjects. The frequency of E’ (extrapeditive score) was

significantly more in the total pattern of the patients than that of the control group (p =

0.004). There was no significant difference between the patient and the control groups

with regard to other factors. Higher E’ scores indicate that the presence of the frustrating

obstacle was insistently pointed out more frequently by patients than controls. This

finding is in keeping with higher mean score on OD in the patient group.

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Conclusion

Hypothesis H1 is rejected and it is concluded that significant differences exist between

the patient and the control group on reactions to frustrating situations as measured by the

Rosenzweig’s Picture Frustration Study. It was observed that, although the patient group

was superficially well adjusted, as evident by the Group Conformity Rating score, the

patient group was deficient in other areas. The patient group had deficiencies, both in the

type (higher scores on obstacle dominance) and direction of aggression (lower scores on

imgression); superego defence patterns (lower scores on intropunitive deviant and

combination of intropunitive deviant and imgression); and pattern of 3 most frequent

responses (higher frequency of extrapeditive scores). Thus, efforts to overcome the

deficiencies should be a part of management of conversion disorder in adolescents in

order to achieve early recovery and to prevent relapse.

These conclusions of this study are tentative in view of lack of previous comparable data

and limitations mentioned below.

Limitations of the study

1. Since only school going adolescents were selected for the study, the findings in

the Rosenzweig’s P-F Study cannot be generalized for the adolescent population

not attending school.

2. The adult form of the Rosenzweig’s P-F study with adult norms has been used in

this work. However, the authors themselves have mentioned that the same can be

used in adolescents.

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3. Group Conformity Ratings were available only for 12 of the 24 items of the

Rosenzweig’s P-F Study.

Future directions

Special efforts should be made to overcome the above mentioned limitations. Further

work should be directed at studying reactions to frustration in association with

important psychosocial variables such as classroom environment, home environment,

sports/ extracurricular activities and experience of stressful life events, in adolescents

with conversion disorder, for elucidating the psychodynamics of the disorder.

Work attributed to: Department of Psychiatry, Institute of Medical Sciences, Banaras

Hindu University, Varanasi

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Dr. Narayana Keertish, Associate Professor, Department of Psychiatry, BGS Global

Institute of Medical Sciences, Bangalore.

Dr. Indira Sharma, Professor and Head of Department and Head of Child and Adolescent

Psychiatry Unit, Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu

University, Varanasi.