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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 301-303

Yearning for a brother: A unique sociocultural risk factor for conversion disorder among children


Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission18-Jul-2020
Date of Acceptance01-Sep-2020
Date of Web Publication08-Oct-2021

Correspondence Address:
Dr. Prahbhjot Malhi
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_218_20

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  Abstract 


Conversion disorder is a common problem, with varied presentation, with which children present to tertiary care centers in India. Currently, reports regarding psychogenic nonepileptic seizure (PNES) in children who face sociocultural stressors are lacking. The present case report shows how PNES can result from psychological distress caused by sociocultural factors, such as preference for male children and gender-based inequality. The case report underscores the need to promote more gender egalitarian attitudes to dispel deep-rooted cultural preferences for sons as these are related to perpetuating and precipitating stress and unhealthy behaviors among the female gender.

Keywords: Children, conversion disorder, gender-based inequality, sociocultural


How to cite this article:
Barman P, Agarwal A, Bharti B, Malhi P. Yearning for a brother: A unique sociocultural risk factor for conversion disorder among children. Indian J Soc Psychiatry 2022;38:301-3

How to cite this URL:
Barman P, Agarwal A, Bharti B, Malhi P. Yearning for a brother: A unique sociocultural risk factor for conversion disorder among children. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:301-3. Available from: https://www.indjsp.org/text.asp?2022/38/3/301/327825




  Introduction Top


Conversion disorder is a common problem, with varied presentation, with which children present to tertiary care centers in India. The symptomatology of the disorder is diverse; however, psychogenic nonepileptic seizure (PNES) is by far the most common presentation.[1],[2] Emotional distress secondary to early adverse childhood experiences combined with precipitating events plays a critical role in the presentation of symptoms, and it is suggested that overly medicalizing the problem may lead to needless investigations and delay the initiation of timely psychological interventions.[3],[4],[5]


  Case Report Top


A previously healthy 9-year-old girl, hailing from a village in Punjab, presented to the child psychology outpatient department of a tertiary care hospital, with a 2-month history of several episodes of abnormal movements of arms and legs, clenching of teeth, and crying. These episodes generally occurred while the child was seated or lying down, lasted several minutes followed by a brief period of confusion. She had a brief admission in a private hospital and was prescribed clonazepam with some relief. However, her symptoms progressively worsened from occasional to several episodes in a day. Clinical evaluation conducted in the hospital confirmed no clear organic dysfunction and the electroencephalogram (EEG) was normal. There was no significant antenatal or birth history, or a history of falls, trauma, involvement of bowel/bladder, cranial nerves, preceding viral illness, recent immunization, or toxin ingestion. The child remained conscious throughout the episode and could demonstrate it on suggestion. She was scholastically bright with no significant history of academic or peer pressure. Suspecting a functional etiology, a detailed psychosocial evaluation revealed myriad causes for stress and difficulties in the family dynamics. The child was eldest of three siblings and had two younger sisters and lived in an extended family. After the birth of a third daughter in the preceding year, which was mourned by the extended family, the mother reported experiencing grief, rejection by her in laws, and several episodes of unresponsiveness, which were witnessed by the child. Family discussions often centered on the importance of a “brother” for the sisters and inability of the mother to provide an heir who would continue the family name. The symptoms of the index child got precipitated a day after the festival of “rakhi” which was celebrated in the school. The child repetitively complained of not being able to participate in the festivities as she had no brother on whom she could tie a “rakhi” as her classmates. The three wishes test, used to gain an understanding of the child's current psychological concerns, revealed an intense wish for a brother and this was supported by her family drawing [Figure 1].[6] In view of her normal clinical examination and EEG report, a psychosocial history with a clear temporal contiguity with a triggering event, and the presence of a role model, a diagnosis of PNES was made. The child's diagnosis and the possible etiological stressors were shared with the family, and these were initially met with disbelief, followed by gradual acceptance. The mother also confessed that she had been deeply disappointed at the birth of her third daughter and to overcome her disappointment had taken recourse to dress the baby girl as a boy. Psychological management aimed at providing supportive therapy, repairing the mother-child relationship, normalization of the child's routine, and increased attention to healthy behaviors of the child rather than to symptoms. After three sessions of therapy, the child gradually started to improve and her symptoms completely resolved after 4 months of therapy.
Figure 1: Family drawing of child's siblings

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  Discussion Top


The diagnosis of conversion disorder is not easy, and a comprehensive psychological assessment is generally needed to unearth stressors of etiological relevance, including traumatic experiences, family conflict, and unresolved grief.[1],[2],[7] Pediatricians often feel helpless when they are faced with a child whose symptoms lack an organic basis and sharing the diagnosis with parents is often met with skepticism and at times with anger and hostility. Indeed, a clear formulation of a psychodynamic explanation for the symptoms provided in an empathetic manner, acceptance of the diagnosis, and prompt treatment can lead to speedy resolution of symptoms and reduce unnecessary medical costs.

India has a long historical legacy of gender-based discrimination and injustices which have been documented to reflect in the health and well-being of children.[8] Desire for sons is deep rooted in our religious and cultural institutions, and there are compelling economic and social reasons, such as patrilocal exogamy and transmission of the family name, for having male rather than female children. The inter-generational transmission of gender attitudes favoring a son is particularly strong in the South Asian countries and can lead to considerable discriminatory gender-based rituals, sanctions, and practices.[9],[10] Clearly then, in a patriarchal society, interventions are urgently needed to promote more gender egalitarian attitudes and shift gender norms for improving health outcomes of girls. The present report highlights the need to consider diverse socially and culturally relevant psychosocial etiological stressors, while evaluating patients who present with conversion symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malhi P, Singhi P. Clinical characteristics [correction of characterstics] and outcome of children and adolescents with conversion disorder. Indian Pediatr 2002;39:747-52.  Back to cited text no. 1
    
2.
Chinta SS, Malhi P, Singhi P, Prabhakar S. Clinical and psychosocial characteristics of children with nonepileptic seizures. Ann Indian Acad Neurol 2008;11:159-63.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Kozlowska K, Chudleigh C, Cruz C, Lim M, McClure G, Savage B, et al. Psychogenic non-epileptic seizures in children and adolescents. Part I: Diagnostic formulations. Clin Child Psychol Psychiatry 2018;23:140-59.  Back to cited text no. 3
    
4.
Roelofs K, Spinhoven P, Sandijck P, Moene FC, Hoogduin KA. The impact of early trauma and recent life-events on symptom severity in patients with conversion disorder. J Nerv Ment Dis 2005;193:508-14.  Back to cited text no. 4
    
5.
Nereo NE, Hinton VJ. Three wishes and psychological functioning in boys with duchenne muscular dystrophy. J Dev Behav Pediatr 2003;24:96-103.  Back to cited text no. 5
    
6.
Kozlowska K, Chudleigh C, Cruz C, Lim M, McClure G, Savage B, et al. Psychogenic non-epileptic seizures in children and adolescents: Part II-Explanations to families, treatment, and group outcomes. Clin Child Psychol Psychiatry 2018;23:160-76.  Back to cited text no. 6
    
7.
Roelofs K, Keijsers GP, Hoogduin KA, Näring GW, Moene FC. Childhood abuse in patients with conversion disorder. Am J Psychiatry 2002;159:1908-13.  Back to cited text no. 7
    
8.
Stark L, Seff I, Weber A, Darmstadt GL. Applying a gender lens to global health and well-being: Framing a Journal of Global Health special collection. J Glob Health 2020;10:010103.  Back to cited text no. 8
    
9.
Dhar D, Jain T, Jayachandran S. Intergenerational transmission of gender attitudes: Evidence from India. J Dev Stud 2019;55:2572-92.  Back to cited text no. 9
    
10.
Gupta GR, Oomman N, Grown C, Conn K, Hawkes S, Shawar YR, et al. Gender equality and gender norms: Framing the opportunities for health. Lancet 2019;393:2550-62.  Back to cited text no. 10
    


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