VISUAL CONVERSION REACTION IN CHILDREN

Dr Simon Barnard
PhD BSc FCOptom FAAO DCLP DipClinOptom

Department of Optometry & Visual Science
City University
London, UK

3^rd Year Lecture

This lecture is based upon:- Chapter 20: Psychosomatic visual anomalies, Pediatric Eye Care, Eds.Barnard & Edgar (1996), Blackwell Science, Oxford

For full details of references, see Barnard & Edgar (1996)

Outline of lecture

• Aetiology
• Epidemiology
• Signs and symptoms in primary eye care practice
• Investigation and (tentative) diagnosis
• Management by the eye care practitioner

What are psychosomatic anomalies?

Physical conditions in which emotional factors play an important part

From psychosomatic = "psyche" + "soma"

Organic disorders

Examples

• pneumonia
• appendicitis
• glaucoma

but can the patient’s emotional state affect recovery ?

Psychosomatic disorders

Psychopathology and physiology are so closely associated that both components actively and concurrently contribute to the natural course of the disorder.

Aetiology

• Very complex and more than one cause.
• One example of the process causing these anomalies would be a theory of Freud who developed the concept of Oedipal genital conflicts (Freud ,1910).
• Unconscious "conversion" of psychic energy into physical symptoms producing "CONVERSION hysteria"
• However, hysteria is NOT the only cause of psychosomatic visual anomalies and the term "hysteria" has connotations. There is confusion in many lay persons and even health care practitioners understanding of the differences between "hysteria" and "malingering"
• So, abandon the term "hysteria" unless a specific psycho-clinical diagnosis has been made by the appropriate practitioner (Barnard 1996)

Epidemiology

Incidence

Mantyjarvi 1.4 cases/1000 children (7-18 years)/year.

Prevalence

Eames (1947) 9% of 193 unselected children exhibited tubular fields. A third of these children had hysterical personalities.

Personal experience (Dr Barnard) is that VCR is not uncommon in a busy paediatric practice and may be more prevalent amongst large orthodox religious families.

Age & sex

Youngest in literature (Wolpe, 1953) is a 2-year old with amaurosis.

Modal peaks (all literature) occur at 10-11 and 13-14 year-old age groups.

4 times more common in females why ?

Signs & symptoms (from the literature)

• Binocular (rare) & monocular blindness
• Amblyopia (LP to 6/9)
• Fluctuating acuity between visits and with suggestion
• Monocular hemanopia, bitemporal and binasal defects, ring scotoma, tubular fields, spiral fields, star-shaped fields, static quantitative anomalies
• Diplopia
• EOM paralysis (VI N palsy) (Melkoff, 1980)
• Paralysis, spasm and sluggish accommodation
• Elevated absolute dark adaptation thresholds (exhaustion phenomenon) (Krill, 1967)
• Total colour blindness, non-recognition of Ishihara demo plate, inconsistent test results
• Disturbances of reading and writing
• Frequent blinking
• Blepharospasm
• Pain in the eyes

VCR versus Organic disease

VCR versus Malingering

Raising the index of suspicion

• Improvement of vision with suggestion
• Size constancy
• Stereopsis
• Binocularity
• Mirror in face
• Visual fields
• Colour vision
• La belle indifference

Management of VCR by the eye care practitioner

• Refer to rule out organic disease if anomaly persistent
• Do not confront the patient
• Unless you have the skills of a BAC accredited counsellor (UK) , psychotherapist, clinical psychologist or psychiatris, care must be taken in not to "analyse" too much.
• Explain the clinical findings to the parent with the child present.
• Discuss with parent alone &/or discuss with child alone ?
• Broach possible examples of causes
• Send routine report to GP
• Suggest referral for counselling/therapy ?

Author’s e-mail address: sb@eye-spy.co.uk