Frustration and fulfillment of needs in dissociative and conversion disorders
Abstract
Abstract We reviewed all patients with dissociative disorders (nine patients with dissociative amnesia or dissociative fugue) and conversion disorders (10 patients) who were admitted and treated during the past 15 years. Needs frustrated at the appearance of the symptoms and those fulfilled at discharge were studied in both groups using Maslow's hierarchy of needs. The patients of both groups who encountered troubles in their life events were found to have frustrated needs. These symptoms tended to be accompanied more often by frustrations regarding a ‘need for love’ in the dissociative disorders group and by frustration in the need for ‘self-esteem and self-actualization’ in the conversion disorders group. In addition, needs of lower orders were already threatened at onset in many patients. The symptoms disappeared in patients in whom the situation completely improved (needs were fulfilled), but the symptoms were alleviated or unchanged in those in whom the problems remained unresolved.
INTRODUCTION
The disease called ‘hysteria’ has been known since the days of ancient Egypt, and its etiology was studied more recently by Briquet, Charcot, Janet and Freud.1,2 Although the condition is recognized today to be a psychogenic disorder, it is classified generally according to the symptoms by contemporary diagnostic criteria such as the Diagnostic and Statistical Manual-IV (DSM-IV)3 and the International Classification of Diseases-10 (ICD-10)4 with apparent disregard of its psychogenic nature. ‘Dissociative disorders’, which present noticeable symptoms related to the loss of memory and consciousness such as amnesia and fugue, and ‘conversion disorders’, which present marked physical symptoms of the functional disorder in voluntary motor and sensory systems,5,6 are both considered to provide a defense against over intense libidinal stimulation by transformation of psychical excitation into physical innervation.7 However, the reason these two different types of psychiatric symptoms appear from the same failure of defense remains to be clarified.
People encounter various problems in their daily lives (life events). At such times, problems appear in daily needs. However, such needs are not always fulfilled. According to Maslow,8,9 humans have five basic needs, which arrange themselves in hierarchies of prepotency as a pyramid. Generally, their fulfillment is aspired to serially from lower to higher orders until ‘self-actualization’ at the peak is attained. In addition, in daily living, multiple needs rather than a single need also simultaneously occur, and some individuals are psychologically stable due to the fulfillment of needs of higher orders despite frustration of those of lower orders.9 Certainly, there are people who have their ‘needs for self-esteem’ fulfilled and are eagerly pursuing self-actualization although their physiologic needs are frustrated due to physical disorders.
Life events have attracted attention as possible triggers of neurosis, and there have been reports that they affect the premorbid personality,10 that diseases can be differentiated by the degree of discomfort,11 and that hysterical aphonia was triggered by stress of examination and quarrels with peers or spouse.12 Using Maslow's hierarchy of needs it was recently shown that needs are threatened by life events in neurotic disorders and that characteristic needs are frustrated in each subtype.13,14 The needs observed in this study were completely different from what Freud called ‘impulses’, but we examined whether the ‘symptoms’ observed in ‘dissociative and conversion disorders’, which are classic hysteria, are related to ‘frustrated needs’ or are caused by a completely different mechanism.
SUBJECTS AND METHODS
We selected all patients with dissociative amnesia and dissociative fugue among the dissociative disorders and those with conversion disorders among the somatoform disorders that met DSM-IV3 from the patients admitted to the Department of Psychiatry, Hospital of Kyushu University School of Medicine, Fukuoka, Japan, during the 15-year period from 1983 to 1998. This study was conducted using 19 subjects. Any patients aged less than 18 years and those who had other mental or neurological complications including depression, epilepsy, and mental retardation were excluded.
The 19 patients consisted of nine patients with dissociative amnesia or dissociative fugue (dissociative symptoms group) and 10 patients with conversion disorders (conversion symptoms group). These two groups were compared regarding the following 12 items based on clinical records during hospitalization: (i) sex, (ii) age at the onset of hysterical symptoms, (iii) age on admission, (iv) educational background, (v) symptoms observed, (vi) life events around the onset, and (vii) needs frustrated by them. (viii) Maslow8,9 classified basic human needs into five categories including: ‘physiological’, ‘safety’, ‘love’, ‘self-esteem’, and ‘self-actualization’ from lower to higher levels as show in Table 1 (referred to as levels 1–5, respectively). We studied which needs and at what levels of frustration (according to Maslow's scale) was seen in our patients. Clinical records and nursing journals were carefully reviewed so as not to overlook any of the needs observed in the patients. In the present study, the needs for self-esteem were threatened in many cases when the needs for self-actualization were frustrated, and also these two categories were difficult in some cases to distinguish based on the clinical records. Therefore, they were combined for convenience as level 4–5.
| 1. Physiological needs |
| ‘Physical symptoms and disorders’ that cause anxiety or fear that the survival of an individual is jeopardized and experiences that threaten instinctive needs. |
| 2. Safety needs |
| Experiences that make the foundation of the survival of an individual (places, order, and stability) uncertain. |
| For example, death or disease of an intimate person, extreme economic instability, anxiety over expulsion from school or unemployment. |
| 3. Love needs |
| Where individuals value their affiliation to a group, experiences of alienation or expulsion from others in the family, workplace, or community. |
| For example, domestic discord, isolation at the workplace, and loneliness after changing the residence or job. |
| 4. Needs for self-esteem |
| Experiences that deteriorate a person's self-evaluation. |
| For example, failure in the entrance examination for a school that the person has aspired to enter, poor recognition by superiors, gap between the actual self and ideal self, etc. |
| 5. Needs for self-actualization |
| Experiences of frustration of the desire to exert one's maximum abilities. |
| For example, poor performance despite one's aspiration for perfect management, poor responses from students despite one's efforts to be a respectable teacher, failure in one's efforts to be a good housewife, daughter-in-law, etc. |
An example of this process using Table 1 as a reference is presented below.
Case 1 was disappointed in love with a woman who he had dated (level 3: frustration of the need for love). Thereafter, he had an accident while he was driving a car he borrowed from his senior at work, and as his relationship with the senior became awkward, he gradually became isolated at work (level 3: threatening of the need for love). He also began to worry about his parents living in his hometown (level 3: frustration of the need for love). Dissociative symptoms appeared around this time. According to Table 1, the needs that were frustrated at the onset of mental symptoms were level 3. (Needs that remained unfulfilled are indicated by a (–) in Tables 3 and 4. If, for example, the needs of level 3 were not fulfilled, they were indicated by –3rd level.)
| No. | Symptoms | Seizures or convulsions | Circumstances of the appearance of symptoms and level of frustrated needs | Level of frustrated needs |
|---|---|---|---|---|
| Dissociative symptoms group | ||||
| 1 | Absence of memory during the period of fugue. | The patient had been disappointed in love (− 3rd level). He caused an accident when he was driving his colleague's car, and he became isolated in his workplace because of this event (− 3rd level). He was considering taking care of his parents who were living in his home village (− 3rd level). | Needs of the 3rd level | |
| 2 | Unable to recognize her own husband. | The patient fell in love with a man whom she met while taking a walk and married him after 2 years of a one-sided relationship on her part. Symptoms appeared when she quarreled with her husband by imposing her ways too strongly and was told by him, ‘I will divorce you’. (− 3rd level) She felt as if she had no place of her own (− 2nd level). | Needs of the 2nd, and 3rd level | |
| 3 | Did not remember what she was doing. (Did not remember having put her room into order and having been to the ward office.) | The patient periodically returned to her parent’s house to look after her sick father. The symptoms appeared because she did not know how to deal with her mother-in-law (− 3rd level). | Needs of the 3rd level | |
| 4 | Loss of memory about himself and his family after fugue. | The patient sold his house to pay a debt that he accrued because of a traffic accident. While he was experiencing economic difficulty (− 2nd level), he even withdrew money from his mother’s account without permission. His younger brother questioned severely, ‘Are you really working? I will go to your workplace to check”. Symptoms appeared the next day (− 3rd level). | Needs of the 2nd, and 3rd level | |
| 5 | Did not go to the appointed place and went to another place but had no memory during this period. | While the patient was troubled with her relationship with her mother-in-law, she was told to decide whether she and her husband would live with the mother-in-law or not. When her husband decided to live with her mother-in- law (− 3rd level), she felt as if she had no place of her own (− 2nd level) and symptoms developed. | Needs of the 2nd, and 3rd level | |
| 6 | Loss of memory about himself and his family after fugue. | The patient had an arranged marriage but divorced after only 3 months (− 3rd level). When he took leave from work due to low back pain (− 1st level), his work was delayed, and his colleague warned him, ‘You may get fired’(− 2nd level). Symptoms appeared the next day. | Needs of the 1st, 2nd and 3rd level | |
| 7 | Loss of memory during the period of fugue. Dysarthria. | The patient could not assert his own thoughts to meet his parent's expectations. He was pressed by whether he should continue working at his present job (− 4th and − 5th) which his parents had recommended to him (− 3rd level). | Needs of the 3rd, 4–5th level | |
| 8 | Did not remember having stolen a wallet. Numbness of the hand. | The patient devoted himself to work and kept himself busy every day. His wife wanted to divorce him. Symptoms appeared when he became unable to adequately function as a manager (− 4th and − 5th level) and found himself isolated in difficult negotiations with the union (− 3rd level). | Needs of the 3rd, 4–5th level | |
| 9 | Loss of memory about himself and his family after fugue. | The patient was doing work at the dormitory during the holiday season, but he could not finish his assignment and fled after the holidays (− 4th and − 5th). | Needs of the 4–5th level | |
| Conversion symptoms group | ||||
| 10 | Vertigo, lightheadedness, numbness of both arms and legs. | Absence | Symptoms appeared when the patient's father failed in business and thus accrued a large debt (− 2nd level), the patient's engagement to a woman whom he had seen for many years was called off (− 3rd level), and he felt pressure between his superiors and subordinates at work (− 4th and − 5th levels). | Needs of the 2nd, 3rd and 4–5th levels |
| 11 | Numbness in both arms and legs, involuntary tongue movements. | Absence | Symptoms appeared when the patient changed work as he felt uncertain about the future of his company (− 2nd level), but he could not adjust to his new coworkers (− 3rd level), and he was troubled as he could not refuse the work assigned to him (− 4th and − 5th levels). | Needs of the 2nd, 3rd and 4–5th levels |
| 12 | Numbness in both arms and legs, loss of taste, ‘My whole body is numb”. | Absence | Symptoms appeared when the patient had difficulty in his work after changing jobs (− 2nd, − 4th and − 5th levels). | Needs of the 2nd and 4–5th levels |
| 13 | Tremor and weakness of both arms. | Absence | Symptoms appeared when the patient was dissatisfied as she could no longer see the married man with whom she had an affair (− 3rd level), and she had difficulty in her work (− 4th and − 5th levels). | Needs of the 3rd and 4–5th levels |
| 14 | Tremors in both arms. | Absence | The patient's barbershop was managed primarily by his wife because of his inefficiency. His wife suggested divorce (− 2nd and − 3rd levels). When customers visited while his wife was absent, he could not work because of the occurrence of symptoms (− 4th and − 5th levels). | Needs of the 2nd, 3rd and 4–5th levels |
| 15 | Fits of loss of consciousness, instability of the body. | Present | After the patient was transferred to another position (− 2nd level), he had trouble with his work (− 4th and − 5th levels). He was also pressed by his debts (− 2nd level). | Needs of the 2nd and 4–5th levels |
| 16 | Numbness on the left side of the body, paralysis on the left side of the body. | Absence | Symptoms appeared when he was rejected (− 4th and − 5th levels) by the man with whom he had negotiated about compensation for damages caused by a traffic accident (− 2nd level). | Needs of the 2nd and 4–5th levels |
| 17 | Aphonia. | Absence | Symptoms appeared after her second marriage, in which she felt herself to be incompetent as a mother (− 3rd, − 4th and − 5th). In addition, she could not understand her stepson's epilepsy and was troubled by the behavior of her stepdaughter. | Needs of the 3rd and 4–5th levels |
| 18 | Fits of convulsion. | Present | The patient was troubled by an argument with a neighbor about the unlawful use of her lot (− 2nd level). Her eldest son divorced against her wishes and became isolated from her (− 3rd level). The patient also quarreled with her second son's wife's family and became estranged from him (− 3rd level). She saw her family falling apart (− 3rd level). Symptoms appeared when she was waiting for a call that her eldest son made daily after dinner (− 3rd level). | Needs of the 2nd and 3rd levels |
| 19 | Fits of loss of consciousness. | Present | The patient terminated her relationships with lovers (− 3rd level). Her mother frequently quarreled with her father, saying he was unfaithful to her, and they were considering divorce. Symptoms appeared when the patient witnessed one of her parents’ quarrels (− 2nd and − 3rd levels). | Needs of the 2nd and 3rd levels |
| No. | Course after admission (needs fulfillled and those not fulfillled after admission) | Symptoms at discharge |
|---|---|---|
| Dissociative symptoms group | ||
| 1 | The patient found a new job in his home town (4th and 5th levels) during hospitalization, which made it possible for him to take care of his parents (3rd level). He was discharged as his memory was restored. | Resolved |
| 2 | After admission, the patient became certain from her husband's behavior that he would not divorce her (3rd level). After discharge, she lived in a place where she could feel secure (2nd level). No reactivation of symptoms was observed, and she was discharged in a stable state. | Resolved |
| 3 | The patient had trouble with the ward staff and became tired of being hospitalized (− 2nd level). The patient was discharged while she was still uncertain about how she should deal with her mother-in-law (− 3rd level). The symptoms did not improve. | No change |
| 4 | After admission, sleep disorders did not improve. The patient became able to sleep using medication, and the physical condition improved (1st level). As he became able to calmly stay home (2nd level), he was discharged. However, he did not talk about his family (− 3rd level) and did not completely recover his memory by the time of discharge. | No change |
| 5 | Although amnesia persisted after admission, it disappeared as the patient's husband agreed to live separately from his mother (2nd and 3rd levels), and she was discharged. | Resolved |
| 6 | The patient became able to sleep (1st level) and to spend time peacefully in the ward (2nd level). However, he would say, ‘I want to break off these troublesome human relationships and go on a trip’(− 3rd level) and was discharged while the symptoms persisted. | No change |
| 7 | During hospitalization, the patient conveyed his wish to quit his job and to go to college, to which his mother agreed (3rd, 4th and 5th levels). He was discharged as the symptoms improved. | Alleviated |
| 8 | The patient's relationship with his wife improved (3rd level), and his former subordinate visited him to ask for his advice concerning business (3rd, 4th and 5th levels), so he was discharged. | Resolved |
| 9 | Sleep disorders alleviated (1st level), and the patient began able to feel relieved in the ward (2nd level). He decided to return to work (4th and 5th levels) while his memory was not restored. However, the patient was disappointed at the indifferent attitude of his father (− 3rd level). He was discharged after a partial recovery of memory. | Alleviated |
| Conversion symptoms group | ||
| 10 | The patient was discharged as he thought that he was regarded as a necessary member by the company (3rd, 4th and 5th levels) and hoped to return to work (4th and 5th levels). | Resolved |
| 11 | During hospitalization, he decided to change his job (4th and 5th levels), and he was discharged after a resolution of the symptoms as he realized that he would be able to escape from the human relations at the present job. | Resolved |
| 12 | The patient could escape from the troubles concerning his work due to hospitalization. However, he was compelled to leave the hospital after shoplifting. His troubles at work remained unresolved (− 4th and − 5th levels). | Alleviated |
| 13 | Although the symptoms persisted, the patient was discharged as his father decided to accept him (3rd level). However, the patient's troubles with work persisted (− 4th and − 5th levels). | No change |
| 14 | The patient decided not to divorce during hospitalization (2nd and 3rd levels). Although his trouble at work was not resolved (− 4th and − 5th levels), the patient was discharged as the symptoms improved. | Alleviated |
| 15 | The patient's father paid the patient's debt (2nd level). His trouble at work was not resolved (− 4th and − 5th levels). The symptoms were alleviated but not resolved. | Alleviated |
| 16 | The problem of compensation for the damage due to a traffic accident showed hope for resolution after lawyer mediation (2nd, 4th and 5th levels), and the symptoms were alleviated. | Alleviated |
| 17 | After admission, the patient obtained correct knowledge about her stepson's disease, and she could be reconciled with her stepdaughter who had found a job and who had decided to live in a dormitory (3rd level). She was discharged as she felt she could fulfilll her duties as a parent (4th and 5th levels). | Resolved |
| 18 | The symptoms were resolved as her sons, who had become distant from her, began to visit her (3rd level). | Resolved |
| 19 | The symptoms were alleviated as the patient's relationship with her mother improved (3rd level). Her parents are still considering divorce (− 2nd level). | Alleviated |
(ix) Conversion disorders were classified into four groups as subclasses of DSM-IV:3 (a) those accompanied by motor symptoms or defects, (b) those accompanied by sensory symptoms or defects, (c) those accompanied by seizures or convulsions, and (d) those in which symptoms of two or more categories are clearly mixed. According to this subclassification, we divided our patients into those with seizures or convulsions and those without seizures or convulsions. (x) The course after admission was reviewed, and the needs of what levels were fulfilled and the needs of what levels remained frustrated at the time of discharge were studied.
An example of this process using Table 1 is shown below.
Case 1 quit his job during hospitalization, but he secured employment at another position before being discharged (level 4–5: at least no frustration of the needs for self-esteem/self-actualization). The patient worried about his parents before onset, but as his new job was in his hometown where they lived he could thereafter care for them directly (level 3: no frustration of the need for love). As these needs were fulfilled, the needs of levels 3, 4, and 5 according to Table 1 were fulfilled in this patient at discharge.
(xi) Whether there were mental symptoms at discharge or not was also examined. In addition, (xii) the states of mental health on admission and at discharge were evaluated using the Global Assessment of Functioning scale (GAF scale) of DSM-IV.3
RESULTS
No significant difference was observed between the dissociative symptoms group and conversion symptoms group with regard to sex (P > 0.9999; χ2 test, Fisher's exact test), age at the onset of symptoms (P = 0.6828; Whitney's U-test after rank correction), age on admission (P = 0.4373; Whitney's U-test after rank correction), or educational background (P = 0.8584; Whitney's U-test after rank correction) (Table 2).
| No. | Sex | Age at the onset of symptoms (years) | Age of admission (years) | Length of education (years) |
|---|---|---|---|---|
| Dissociative symptoms group | ||||
| 1 | Male | 20 | 20 | 12 |
| 2 | Female | 42 | 42 | 9 |
| 3 | Female | 32 | 32 | 12 |
| 4 | Male | 36 | 37 | 9 |
| 5 | Female | 43 | 43 | 14 |
| 6 | Male | 33 | 33 | 12 |
| 7 | Male | 20 | 20 | 12 |
| 8 | Male | 53 | 56 | 16 |
| 9 | Male | 23 | 23 | 12 |
| n = 9 | Male (66.7%) | 33.6 years old | 34.0 years old | 12.0 years |
| ± 10.7 (SD) | ± 11.3 (SD) | ± 2.1 (SD) | ||
| Conversion symptoms group | ||||
| 10 | Male | 27 | 30 | 12 |
| 11 | Male | 41 | 41 | 9 |
| 12 | Male | 47 | 57 | 14 |
| 13 | Female | 21 | 21 | 12 |
| 14 | Male | 44 | 44 | 9 |
| 15 | Male | 35 | 42 | 12 |
| 16 | Male | 31 | 34 | 12 |
| 17 | Female | 27 | 27 | 14 |
| 18 | Female | 73 | 73 | 14 |
| 19 | Female | 26 | 27 | 12 |
| n = 10 | Male (54.5%) | 37.2 years old | 39.6 years old | 12.0 years |
| ± 14.4 (SD) | ± 14.9 (SD) | ± 1.7 (SD) |
In the dissociative symptoms group (Table 3), Cases 1, 4, 6, 7, and 9 showed amnesia with fugue, but the other four patients showed only amnesia. (Cases 8 and 9 who exhibited conversion symptoms at the onset were included in the dissociative symptom group because they developed dissociative symptoms as primarily problems in the subsequent course.) In the conversion symptoms group (Table 3), seizures or convulsions were observed in Cases 15, 18, and 19.
Table 3 shows the situations at the time of the appearance of mental symptoms and Maslow's need levels to which the situations corresponded. In the dissociative symptoms group, the needs of level 3 (needs for love) were frustrated in eight (88.8%) of the nine patients at the appearance of mental symptoms. The remaining one patient (Case 9) was later shown to be alienated from his parents and to be isolated (needs for love was threatened). In the conversion symptoms group, level 3 needs were frustrated in seven patients (70%) similarly to the dissociative symptoms group, but levels 2, 4, and 5 needs were frustrated in eight patients (80%). The two patients (Cases 18, 19) who developed conversion symptoms due to frustration of needs of level 3 (needs for love) were both female. In these patients, the symptoms appeared when they were isolated (the need for love were threatened) in a situation in which level 2 or level 3 needs had been frustrated. In addition, many patients with conversion disorders suffered from two or three needs simultaneously.
Seizures or convulsions were observed in three patients in the conversion symptoms group. Levels 2 and 3 needs were frustrated in two patients, and levels 2 and 4 needs were frustrated in one, at the appearance of the seizures or convulsions. The first two patients were females and the last one patient was a male. While level 3 needs (the needs for love) were frustrated in the first two patients, the needs of level 4–5 (self-esteem/self-actualization) were frustrated in the last one male (Table 3).
The patients in whom the symptoms disappeared by discharge either abandoned the past situation (work and/or human relations) that frustrated their needs and turned to a new field of activities (Cases 1 and 11) or had their troubles resolved (fulfillment of needs) and restored the previous state (Cases 2, 5, 8, 10, 17, and 18). However, the symptoms were simply alleviated when ‘actual troubles’ were exposed but remained unresolved even after turning for other directions or partial fulfillment of the needs (Cases 7, 9, 12, 14, 15, 16, and 19). The symptoms were unchanged in the patients who were discharged with all problems remaining unresolved (Cases 3, 4, 6, and 13).
Table 4 shows both changes of needs after admission and at discharge in each group. In the dissociative symptoms group, the symptoms disappeared in four, were alleviated in two, and were unchanged in three patients. In the conversion symptoms group, the symptoms disappeared in four, were alleviated in five, and were unchanged in one patient. The outcome was not significantly different between the two groups (P = 0.6934; Whitney's U-test after rank correction).
The GAF score on admission (P = 0.4101; Whitney's U-test after rank correction) and the GAF score at discharge (P = 0.4076; Whitney's U-test after rank correction) were not significantly different between the dissociative symptoms group and the conversion symptoms group (Table 5).
| No. | Admission | Discharge |
|---|---|---|
| Dissociative symptoms group | ||
| 1 | 55 | 90 |
| 2 | 80 | 90 |
| 3 | 51 | 64 |
| 4 | 41 | 50 |
| 5 | 51 | 67 |
| 6 | 54 | 67 |
| 7 | 55 | 90 |
| 8 | 51 | 90 |
| 9 | 51 | 70 |
| n = 9 | Mean 54.3 | Mean 75.3 |
| Conversion symptoms group | ||
| 10 | 57 | 87 |
| 11 | 57 | 67 |
| 12 | 54 | 60 |
| 13 | 20 | 57 |
| 14 | 41 | 41 |
| 15 | 67 | 67 |
| 16 | 80 | 91 |
| 17 | 80 | 90 |
| 18 | 67 | 87 |
| 19 | 20 | 60 |
| n = 10 | Mean 54.3 | Mean 70.7 |
DISCUSSION
The amnesia and fugue observed in patients with dissociative disorders, and manifest physical symptoms (sensory and motor disorders) observed in patients with conversion disorders among somatoform disorders are considered to be based on psychogenic mechanisms, but their causes remain unclear thus making their treatment difficult.
In conventional treatment, various therapeutic techniques are used to achieve a cure based primarily on the hypothesis that symptoms such as Freud described are the result of a failure of a defense against libidinal stimulation and that the liability to failure is largely related to psychological trauma during infancy.15,16 These patients had led generally normal daily lives before the onset with no apparent impairment, but their daily lives were suddenly disrupted by a trivial life event and they developed symptoms that are difficult to understand while they had no neurological or organic disorders. In the present study, we investigated needs frustrated by life events that triggered the onset and troubles that the patients had in their daily living immediately before the onset (threatened needs). These needs are different from the impulses that Freud described.
The results of the present case showed that the frustrated needs differed between the two groups. The need for love was threatened in eight (88.8%) patients in the dissociative symptoms group. Love needs were simultaneously frustrated in two (Cases 7 and 8) of the three patients in whom higher needs for self-esteem were threatened. The remaining one patient (Case 9) was found at discharge to have had a threatened need for parent–child love from before the onset. From these observations, the frustration of the need for love is considered to be a major factor in dissociative symptoms.
In the conversion symptoms group, symptoms appeared due to a frustration of the need for self-esteem self-actualization in eight patients (80%) (Cases 10–17). In addition, the lower needs for love and safety were simultaneously threatened in all patients with conversion disorders. Lower needs for love were also threatened in the remaining two patients (Cases 18 and 19). These two patients were both female and presented with seizure or convulsions as the primary manifestation. Males who showed seizure or convulsions had threatened needs for self-esteem/self-actualization. The occurrence of seizure or convulsions may differ between males and females. According to ICD-10,4 physical symptoms accompanied by seizure or convulsions are included in dissociative disorders, and the classification of these mental symptoms differed between the two diagnostic criteria. Whether this male–female difference is significant must be clarified by future studies.
Many of these findings were obtained based on histories taken at the time of admission. Patients who could return to their original job and improve their human relationships through practical improvements in the circumstances or situation before being discharged and those who sought a new field of activity and had new needs fulfilled were discharged after a complete resolution of symptoms. However, many of the patients in whom one level lower needs were fulfilled were discharged even though the symptoms persisted.
Other information revealed by this investigation was that one to two lower needs had been threatened before the onset of the disease in addition to the frustration of one need in both groups. Maslow observed that some patients retain psychological stability if higher needs are fulfilled even when lower needs are frustrated.8,9 If threatened lower needs are exposed due to a frustration of higher needs, the patient is likely to be confused in coping with them. The occurrence of puzzling symptoms at the onset may be related to the simultaneous threat of multiple needs.
Analysis of the depth psychology in such patients began in the times of Janet and Freud. Janet considered a mental function deficit model that cannot control mental factors due to weakness of the ego.17 Freud, on the other hand, proposed a conflict model of mental functions that has a strong ego and protects itself from psychological pain using the defense mechanism of reppression. Hilgard (1977), a psychologist of the Janet school, advocated the neodissociation theory that patients shift psychic content to other forms rather than have difficulty in suppressing it. Dissociation tends to be perceived as a defense mechanism to overcome critical experience for an individual.18
Dissociative amnesia is considered to occur under stressful or traumatic situations, of which life events such as war, disasters, spouse abuse, and childhood abuse have been suggested as examples.19,20 Dissociative fugue is considered to frequently occur as a result of individual crises accompanied by mental strain such as war, disasters, and extramarital relations.19 In patients with total amnesia, a weak family relationship and loss of a place where the patient can feel secure and comfortable have been reported among dissociative symptoms.21 Such reports simply listed events that were frequently observed. The clarification of how the symptoms of dissociative disorders are caused remains insufficient.20,22 We studied the needs threatened by life events and found that many patients developed such symptoms when their needs for love were threatened. The need for security was simultaneously threatened in some patients. The symptoms disappeared completely as the needs for love were fulfilled in the encountered patients with dissociative disorders. These findings support Hilgard's view17 in which needs are simply shifted to another form by a vertical split. Dissociation may be called psychic suicide23 for those who suffer from the frustration of needs for love and the loss of something they rely on.
Conversion disorders, in contrast, have been reported to have occurred in soldiers in combat situations19 and to have been caused by stressful life events24 such as undergoing examinations and having discord with colleagues or spouses.12 We studied the frustration of the needs for self-esteem and self-actualization caused by life events. Among the patients with conversion disorders, the symptoms disappeared in those who found a new job or a new role but persisted in those who were discharged without finding this. We did not analyze the depth psychology, but such persistence of symptoms was observed in patients who had frustrated needs for self-esteem/self-actualization. This is considered to be a phenomenon explained by using Freud's conflict model. Sakurai suggests that care is required to not damage the patient's self-esteem in psychoanalytical treatment for conversion disorders,16 and our observations appear to support this view.
Recently, positive relationships of post-traumatic stress disorder with dissociation and somatization have been suggested.25 In the present study, the relationships between dissociative disorders and the needs for love and between conversion disorders and the needs for safety, love, and self-esteem/self-actualization were revealed. Further studies on the relationships between frustrated needs and traumatic experiences are considered to be of interest.
The patients of both groups enrolled in the present study received drug therapies using routine doses of antianxiety drug or antidepressive drugs, but the drugs used were not fixed. The contribution of drug therapies to improvements in mental symptoms cannot be ruled out. However, in our study, we investigated a recovery of frustrated needs which is difficult to improve by drug therapies alone. According to a white paper published in 2000,26 95.8% of Japanese graduated from high school, and 44.1% of high school graduates advance to junior college or college. Although the time of investigation was different, 52.6% of our patients were high school graduates, and 26.3% were junior college or college graduates. Therefore, the educational level of our patients may have been lower than the national average. Certainly, conversion disorders have been reported to occur more frequently in rural residents and individuals with a low educational level, a low intellectual quotient, and a low socioeconomic status.19 However, the needs levels described by Maslow are unrelated to the educational level. For example, even persons with a low level of intelligence or culture is considered to have attained a high level of self-actualization if they are doing their best for the well-being of others and themselves.
The lower level needs were threatened before the onset in many of our patients, and the fulfillment of these lower needs appeared to be effective to an extent for the alleviation of symptoms. However, the complete disappearance of symptoms was only observed in those who perfectly restored their previous positions or environment and those who abandoned the past, obtained a new job or role, and were discharged with a positive outlook.
In the subjects investigated in the present study, the symptoms disappeared rapidly when their practical needs were fulfilled, but the needs may again be readily frustrated and therefore might possibly recur unless the experience of infantile psychological trauma described by psychoanalysts can be completely cured. The relationship between practical needs and the impulse of the analytical school must still be further evaluated.
SUMMARY
Frustrated needs observed in frustrating situations were investigated on admission, and whether these needs were fulfilled was examined at the time of discharge. These needs were not the same as the impulses described by Freud, and the onset tended to be accompanied by a frustration of needs for love in the dissociative symptoms group and the frustration of needs for self-esteem/self-actualization in the conversion symptoms group. The symptoms disappeared when these needs were fulfilled, and the patient's life returned to the state before the onset. Because the number of patients in this study was small, a further evaluation with a larger number of subjects is necessary. It is also necessary to apply the method employed in the present study for the treatment of so-called hysteria and to evaluate whether therapeutic intervention by positively correcting the patient's actual life from an early stage of treatment while also trying to improve the degree of fulfillment of frustrated needs is effective.
