The neurologists we interviewed had a wide range of views on conversion, many of them clearly reached after a great deal of careful thought. They may have been an unusual group, of course, being metropolitan to a degree, attached to an academic unit, but also with comparatively ready access to neuropsychiatry. We spoke with the majority of the neurologists in the region, and our ‘snowball sampling’ should have helped us to capture the full range of views. A sample collected and analysed in this way cannot claim to accurately represent the frequency with which views are held, but it does aim to robustly characterize the conceptual spread.
The neurologists described a number of ways of understanding ‘conversion disorder’. Symptomatically, it was seen as a more severe unexplained condition where a neuropathological explanation was unlikely to be forthcoming; they also acknowledged that there was probably a psychological explanation, but did not feel this was their concern; and they also found the distinction from feigning much less clear than the psychiatric manuals would mandate, again without feeling this distinction was necessarily important. This tells us that many neurologists like to see their authority and responsibility ending when the neuropathological explanation has been excluded: they can be ‘agnostic’ about what other explanations are effective, whether these are psychological or social. This is an appealing position, supported by both neurology (Hallett, 2006
) and psychiatry (Miller, 1988
). The exclusion of organic pathology can be done effectively (Stone et al
), and the confusion about mechanisms left to psychiatrists. But there are problems with this ‘agnostic’ stance.
Firstly, although this delimited role is appealing, it may not be realistic: conversion may be considered a primary psychiatric disorder (by psychiatrists, at least), but it is managed largely by neurologists (Mace and Trimble, 1991
). This would seem to put neurologists in the difficult position of operating outside of their perceived expertise. But there are several ways in which expertise can be understood: it might reflect a particular understanding, a therapeutic technique, or extensive experience. On the basis of experience, neurologists could clearly claim considerably greater expertise than psychiatrists. And, as described in the introduction, the psychiatric claim to greater insight or therapeutic expertise is also in question as psychoanalytic models continue to lose ground within the profession. Neurological expertise may be importantly different, but they are experts nonetheless.
Secondly, many of the neurologists are not simply ‘agnostic’, they are avoidant: they believe or suspect feigning in many cases, but do not, for a variety of reasons, pursue it (Kanaan and Wessely, in press). While many acknowledged this freely, there were others whose discussion suggested it—in giving ‘conversion’ examples which involved feigning, or in the ready ‘Freudian slips’ into such language as ‘fictitious’ or ‘not real’ when speaking of their conversion patients’ symptoms.
Thirdly, neurologists making a judgement about origins would explain what is otherwise puzzling about their division of the unexplained. The neurologists had a hierarchy of the unexplained, dividing them into those which could probably be explained (if circumstances permitted) and those which could not possibly be so in the current scheme. Thus ‘impossibility’ would seem to be how conversion was identified. And saying a symptom was ‘impossible’ would seem to imply that there must be some kind of different explanation, without saying what kind of explanation that is—an agnostic position. But deciding that something is impossible—that it is incommensurate with a scientific model—cannot readily be done in practice: there are always further conditions, further refinements which can be made to accommodate exceptions (Feyerabend, 1970
). Consider the example most cited, of the gross inconsistency between function on-and-off the examination couch. This is certainly odd, but not clearly impossible: it merely requires an impairment which varies with the context, of which there are multiple other examples from neurology. Some additional, prior conception is required—something which argues that this kind of inconsistency is different from the inconsistencies that could be physically explained. That conception could be ‘malingering’—conscious control: the neurologist could compare the symptoms with those that they might themselves consciously adduce. The gross inconsistency of their patient would not be impossible therefore, but it would be implausible: it would be exactly what they would do if they were pretending to be paralysed.
Of course, it is unlikely that our neurologists are approaching this entirely as scientists; it is much more likely that they employ various clinical heuristics and recognize certain patterns as being those which predict a diagnosis of conversion. Conversion patients are just those with particular patterns of symptoms, of inconsistency, of disability, of illness behaviour, of how they make neurologists feel. But then the question would be why this cluster of negative features comes to be associated together, and why is there this residual association with ‘malingering’, after 100 years of psychiatric orthodoxy saying otherwise?
There are three ways in which we might understand this. First, that these are simply associated features of the disorder—the neurologists are merely correctly identifying them. Patients with conversion disorder have deceptive, behavioural or psychological characteristics that evoke these responses in people. They are just unlucky enough to have a condition, a ‘natural kind’ (Kendell and Jablensky, 2003
) that makes people dislike and distrust them. But this does seem to objectify the dislikeable and to blame the patient, so the alternative view has been that these characteristics are actually features of the neurologist: patients with conversion put the neurologist in the unwelcome position of having to admit the limits of their competence, which the neurologist projects onto their hapless patient as dislike. This view updates a long tradition in hysteria revisionism, which has sought explanations for hysteria in the broader relationships of doctors with their patients—for example, in the historical reinterpretation of hysteria as misogyny (Micale, 1995
). But it does not explain why just these patients, of all the unexplained, should be thought of in this way. The third view, the view we present here, is somewhat different, and is in essence that ‘malingering’ is actually the preferred model for the neurologists—it is the defining conception we searched for above, and any other pejorative associations flow from that.
This would argue that the neurologists are not agnostic after all: that they know a great deal about conversion, and that deception is the basis on which they understand it.