Localizing the Wandering Uterus

MEDICINE & HEALTH/RHODE ISLAND The natural history of conversion disorders in general is interesting. The vast majority resolve without treatment in the first few weeks, while those that persist for several months generally persist forever. These are often disabling, and no treatment is known to be effective. The patients generally do poorly. The neurologist dismisses them with, “no neurological disorder;” then the psychiatrist dismisses them with “no psychiatric disorder.” Only recently have some neurologists followed these patients, even if the etiology of the disorder is psychiatric, just as we follow people with untreatable degenerative disorders. This is support and is important, but it is not treatment, at least not specific treatment. While many of these patients share a variety of common psychiatric comorbidities, such as childhood abuse, personality disorders, post traumatic stress disorders, not all do, and many, on the surface, appear to not have much in the way of psychiatric dysfunction. This, of course, makes life hard for the psychiatrist and, worse for the poor patient. In recent years, studies have tried to figure out “how” rather than “why” conversion disorders occur, by using fMRI, a crude measure of brain activity, while the patient has conversion symptoms, and comparing the results to normal controls feigning the same disorder. In one study, the conversion patients had intermittent tremors and the fMRI were obtained while the patient had the conversion tremor and then again when the same patient voluntarily mimicked the tremor, thus acting as his own control. The fMRI patterns differed when the conversion disorder patients had their conversiontremor, presumably voluntary but unconscious, from when they feigned the exact same tremor. This implies that physiological underpinnings explain how some patients develop neurological symptoms which are generated unconsciously. These physiological alterations will not explain why some patients develop these problems but may, in time, suggest how to treat them. It is not clear in this early stage whether this imaging modality will allow us even to diagnose the problem. These studies are important because conversion disorders are common, confounding to all involved and may provide insights into the dynamics of unconscious Localizing the Wandering Uterus Commentaries