An Inexplicable Illness Among Pakistani Women
In a country where women often have few outlets for emotional expression, many develop conversion disorder, characterized by pain, paralysis, and other psychosomatic symptoms in response to stress.
Yasmeen lies slack-jawed on a bare metal cot in a secluded part of the largest hospital in Northwest Pakistan. She stares blankly whenever her mother spoons lukewarm tea into her mouth. Half of her body is paralyzed. Though doctors have found no physiological or neurological explanation for her immobility, Yasmeen, 14, can’t move her left arm or leg.
“We sent her to the physiotherapist, and then we had our own exercises here in the ward, too,” says Mahvish Karamat, a psychologist based in the psychiatric ward of Lady Reading Hospital in Peshawar, Pakistan. “The physiotherapist said that she has no [physiological] problem, but that she should exercise these limbs. Otherwise this can lead to a [physiological] case of paralysis.”
According to her doctors, Yasmeen suffers from conversion disorder, a condition that can cause a range of symptoms including pain, numbness, tremors, blindness, or even paralysis in patients without an identifiable, organic source. Although they might garner additional attention for their mysterious symptoms, patients diagnosed with such psychosomatic disorders are not faking. As one medical reference book puts it, “Some doctors falsely believe that this disorder is not a real condition and may tell patients the problem is all in their head. But this condition is real. It causes distress and cannot be turned on and off at will.”
Cases of conversion disorder abound at Lady Reading, a colonial-era hospital built mostly of red bricks in the shade of the Bala Hissar Fort. Both are now on the front lines of the region’s battle with terrorism, one deploying troops and one treating victims. I came to the hospital’s psychiatric ward to learn how the conflict has affected people, but found that the sort of conflict that has the biggest impact on people’s lives doesn’t as often make headlines.
The drab, gray walls of the hospital’s psych ward are adorned with homemade posters. They’re bordered with bright-pink flowers and cartoon characters, but depict serious subjects: One is labeled “psychotherapeutic measures” and another “dissociative disorders.”
Dissociative disorders, the group of psychosomatic psychiatric illnesses that includes conversion disorder, according to the World Health Organization (WHO) classification handbook ICD-10, was the second most common diagnosis (after depression) made among female patients admitted to Lady Reading’s psych ward between January and November of last year. The ward diagnosed 23 dissociative cases last January, compared to only four cases of schizophrenia, two patients with mood disorders, and none with anxiety.
The 16-bed female ward is almost always full. There is only one psychiatrist for every 100,000 people in Pakistan, according to the WHO. Mental health facilities are particularly rare in the restive and conservative tribal areas in the country’s northwest, and some traverse mountain roads for hours to receive medical treatment in Peshawar. One possible explanation for the prevalence of conversion disorder at Lady Reading could be that the severity of conversion symptoms is enough to spur patients to travel to the hospital, but some local doctors believe that that conversion is a common psychiatric disorder among women here.
“We have a lot of conversion patients because women are suppressed,” Karamat says. “The culture is very strict and it’s a male-dominated society, so women’s rights are violated. Other than that, it’s because we don’t have many spaces for women to get out and enjoy their lives: That trend is nonexistent here. We don’t have any social parks and women can’t really even go out to eat. So because of that, women are bound to the house. That causes them to bury their emotions and develop frustrations. Then they come up with physical symptoms. Sometimes they come with pain, or body aches, and most common is fits, [which are called] conversion fits or non-epileptic seizures.”
The notion that repressed trauma or latent desires might be “converted” into physical ailments has been at the core of how mental-health professionals have dealt with the disorder for at least the last hundred years. This theory was popularized, perhaps unsurprisingly, by Sigmund Freud, who thought that repressed memories or the impossibility of fulfilling a sexual drive would manifest itself physiologically as fainting spells or the inability to speak.
But for decades after Freud’s death, European women still carried vials of “smelling salts.” It was commonly believed that their pungent odors would settle their uteruses and there deflect “hysteria.” First described among women in ancient Egypt in the second millennium B.C., the “wandering uterus” was believed to cause everything from anxiety attacks to depressive periods.
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Since then, it’s not just an understanding of conversion disorder that’s evolved. Many experts have theorized that societies can evolve away from the condition.
“From an epidemiological perspective, conversion disorder as a pathological condition disappeared almost, if not completely, from many developed societies,” Wen-Shing Tseng wrote in his Handbook of Cultural Psychiatry in 2002.
“It is thought to occur primarily in societies with relatively strict social systems, in which people cannot express their feelings or desires toward others directly, particularly when they encounter conflict or distress,” he continued. “Temporary somatic dysfunction is one mode of communication available to people, particularly for a suppressed gender or less-privileged group of people.”
The theory that social liberalization nullified the conditions in which conversion disorder might arise has gained recognition, even though there’s not much evidence to support it.
The theory didn’t hold up in one of the only broad, cross-cultural studies of medically-unexplained bodily complaints. Of 15 cities sampled, the highest prevalence of inexplicable symptoms was in Santiago, Chile, followed by Rio de Janeiro, Brazil; Ankara, Turkey; Berlin; and then Manchester in the United Kingdon. Notably, Ibadan, a city in Nigeria, had the lowest percentage of cases in the study.
“It’s a nice idea that in societies where people can’t express themselves, they would have a physical symptom, but I don’t think the evidence supports it,” says Jon Stone, a clinical neurologist based at the University of Edinburgh.
“There’s various reasons for why that [idea] gained prominence,” he says. “But I think it’s a slight superiority issue that the West has [that makes us think] ‘We’re more sophisticated’ or ‘We’ve moved on.’”
Another issue that makes it difficult to make such an assertion is how different health systems function across countries. In a paper he co-authored, an additional explanation for why “hysteria” appeared to decline in developed societies was the way health and education systems deal with the disciplines of neurology and psychiatry.
“Neurologists were not interested in seeing the [conversion] patients and the patients were mostly not interested in seeing psychiatrists,” he writes, along with four other experts on the topic. Treatment of the disorder fell into a chasm between the two.
Stone has also argued against the theory that all patients with conversion disorder have repressed feelings or memories. He was one of the advisers to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which no longer requires the presence of a psychological stressor for a diagnosis of conversion disorder.
“A lot of the time, these symptoms just happen in the same way that people get migraines, or some people get anxiety when they’ve not had anything stressful happen to them,” he says.
“For example,” Stone says, “I had a patient who had a high fever, and they were shaking because they had a high fever, and when the fever went away, they just carried on shaking.” Stone is more interested in a view that considers past injuries or what he calls “mechanisms” instead of the mysterious source of psychological stress that so captivated Freud.
Searching for some uncharted bit of repression or trauma can be an endless quest, and often, at least at Lady Reading Hospital, there just isn’t enough time to draw out details.
Yasmeen, the paralyzed 14-year-old girl, didn’t speak a single word before she was discharged. Her mother described their home life and it was from what she told them that psychiatrists and psychologists identified a stressor: a sister who had recently moved with her baby back into the family home—already crowded with 10 other children.
The continued reliance on finding a basis for conversion in a patient’s past comes partially from a belief in Freudian ideals. Dr. Zayed Nazir, a psychiatrist and professor based at Lady Reading, describes a lot of his cases in terms of the id, ego, and super-ego. But for many patients, identifying such a cause helps drive home the importance of attending to mental health needs. Follow-up visits are virtually is nonexistent and it's often impossible for doctors to know if there was any compliance with prescriptions or even improvement in symptoms.
Before I leave the hospital, I follow Nazir into what he calls “the battlefield.” This is where psychiatrists consult with patients who’ve arrived at the hospital for outpatient care, but who don't appear to have any medically identifiable causes for their concerns.
The first patient Nazir sees is a girl named Seema, who is 15 years old and travelled two hours to the hospital by bus. She complains of a headache that erupts through her body like, as she says, “an electric current” whenever she touches her head. This occurrence is paired with watery eyes as well as a burning sensation throughout her body, both of which occur throughout the day. “I get angry really easily,” she adds as an afterthought, mainly at her younger brother.
While Nazir moves on to his next patient, I spend some time talking to the girl. At the time, Seema was just months away from taking the country-wide exam that will determine what subjects she can study at the undergraduate level and which colleges she can attend. On top of that, she, like three of her six siblings, was trying to memorize the Quran, a book with 114 chapters in a language she doesn’t speak. She told me, “Sometimes, I struggle to memorize it, and because of that, I get really frustrated and my teachers scold me.”
Still, she said, her schooling and memorizing have nothing to do with the pain in her head. “I have tension because my younger brother hit me on the head with a shoe polish tin that he was swinging around,” she said matter-of-factly. “My younger brother makes a lot of noise and then my head hurts a lot,” she added after a while.
While he asks her to get an eye exam to rule out vision issues, Nazir tells me later, “[Seema] is depressed, but she has physical symptoms: heaviness, headaches. She won’t say, ‘hopelessness, helplessness.’”
In its entry on conversion disorder, the DSM-IV, the previous edition of the DSM, referred to bodily symptoms as a sort of “sign language” for deeper psychological stressors that, again, no longer need to be traced, or even to exist, for the diagnosis of conversion disorder to be made. The DSM-V notes that anything from slurred speech to paralysis or memory loss can be diagnosed as conversion disorder—with or without a psychological stressor. The updated handbook focuses on the symptoms present instead of why they might arise, but the idea that our bodies have a complex and perhaps even incomprehensible language all their own is a hard one to shake.
As much as the notion might play into the sort of “superiority complex” Stone described, there are a lot of reasons why women in particular might be silenced in a place like Northwest Pakistan. Many live with their extended families under a single roof where they may not find a lot of sympathy for their distress. Social restrictions on a woman's ability to travel or work outside of the home still persist. Rampant terrorist attacks and drone strikes haven't made the region any more navigable–or any less stressful. Some of the women at Lady Reading have become loath to share their feelings, so doctors listen closely when they describe physical ailments–even if they defy easy diagnosis. Ultimately, these mysterious symptoms often remain a mystery. And inexplicable symptoms from headaches to paralysis speak to something that much of modern medicine is ill-equipped to remedy—the great divide that's been created between the mind and body.