INDICATORS OF CONVERSION DISORDER PATIENTS

BASED ON HUMAN FIGURE DRAWING TEST

Izaz Jamal1, Zainab Ishfaq2, Haadia Hidayat2, Abdul Hai Wazir3, Ijaz Gul1, Pirzada Muhammad
Muneeb1
ABSTRACT
Objective:

 To ascertain the typical reactions of conversion patients when asked to draw a human figure;
 To explore which bodily organs patients with conversion disorder omit from their drawings;
 To analyse the similarities and distinctions between patients who have conversion disorder and
those who do not.

Methods: This cross-sectional study used purposive sampling to select 100 participants, with 50
having conversion disorder and 50 without, from various hospitals and universities. Data were
analyzed using a standard manual. Descriptive statistics assessed demographics, while the chi-
square test evaluated associations between variables. Correlation measures compared conversion
disorder patients to non-conversion participants.
Results: Significant changes in emotional markers are seen between the conversion and non-
conversion patient groups on the human figure drawing test. Notable indicators among conversion
patients include the deletion of the legs and feet (92%), the entire shade of body limbs (100%), and
the shading of the face (96%).
Conclusion: By analysing emotional signs, this study makes a substantial contribution to our
understanding of conversion disorder. The results demonstrate the potential of Human Figure
Drawing as a diagnostic tool, integrate psychodynamic and cognitive-behavioral techniques, and are
consistent with historical perspectives. Through ongoing advancements and expanded
interdisciplinary collaboration, Human Figure Drawing may play a critical part in the diagnostic
process in cases of conversion disorder, enabling early detection and intervention.
Keywords: Conversion disorder, Human Figure Drawing (HFD), Emotional Indicators, Patient Health
Questionnaire (PHQ-15), Diagnostic Tools.

INTRODUCTION Patients present with physical and neurological

symptoms or organic problems that are not
Conversion disorder is a mental illness in detectable by laboratory testing, making
which there is no apparent medical cause for diagnosis challenging. This disorder is
the physical symptoms of psychological stress, categorized as a somatoform disorder in the
such as paralysis or non-epileptic convulsions. Diagnostic and Statistical Manual of Mental
It presents diagnostic issues since symptoms Disorders, Fifth Edition (DSM-V) and a
might mimic neurological or medical diseases. dissociative disorder in the ICD-10. It is
It is frequently associated with trauma or believed that psychological factors1 are the
stress. primary cause of this condition. Children with
_____________________________________ conversion disorder frequently experience
motor symptoms, which emphasizes the
1Mardan Medical Complex, Mardan importance of early psychological intervention
2Clinical Psychologist and reducing patient defensiveness 2. Further
3Institute of Mental Health and Behavioral investigation into the neurological
Sciences Hayatabad, Peshawar underpinnings of conversion disorder has been
prompted by research indicating that
…………………………………………………….. individuals with the condition perform worse on
information processing speed tests when
Address for Correspondence:
compared to those with physical symptoms
Ijaz Gul
and related conditions3.
Professor, Department of Psychiatry, Bacha
Khan Medical Complex, Mardan Historically, hysteria has been associated with
drgullrh@yahoo.com mental illness, and in the 18th century it
became associated with the brain and
developed into the informal term ``conversion
disorder'' by Joseph Breuer and Sigmund

KJMS July – September 2024, Volume 17, No. 3 147

Freud. Freud identified hysterical symptoms as In order to better understand conversion
a defense mechanism to reduce stress caused disorder, this study looks at its diagnostic
by physical disorders. 4. Freud's therapeutic challenges, historical background, and use of
alliance, using catharsis, hypnosis, and free Human Figure Drawing (HFD) to pinpoint
association, aimed to uncover unconscious emotional indications. It especially examines
conflicts related to aggression, sexuality, and whether conversion patients show more
dependence. 5. pronounced indicators on HFD in comparison
to individuals who are not conversion patients,
Rethinking the relationship between behaviour with an emphasis on the body parts that
and its consequences to help patients let go of conversion patients may choose to remove.
symptoms is a behaviourist approach, as The study compares these drawings in an
learning theory posits that individuals assume effort to evaluate the diagnostic potential of
the role of sickness for external rewards. 6. HFD and to emphasise the need for continued
When there are no underlying medical or research using cutting-edge instruments and
neurological conditions, cognitive behavioural technology.
therapy works well; when there are familial
dynamics involved, family therapy is advised. Hypotheses
7, 8. While family therapy, cognitive There is a significant difference of emotional
behavioural therapy, and psychodynamic indicators on HFD of conversion and non-
techniques are acknowledged as effective conversion
means of diagnosing and treating conversion
disorder, there is no definitive hierarchy among
them. 9. A case study demonstrates how well METHOD
a psychodynamic approach to understanding
conversion disorder works, and family Participants
counselling and cognitive behavioural therapy This was a cross sectional study conducted in
are helpful in the treatment process. 10. various hospitals and universities of Peshawar.
A sample of 100 was taken. The sample was
The Human Figure Drawing (HFD) test divided into two groups. The first group
developed by Good enough serves as a comprised of 50 conversion patients data
projective test with 30 emotional indicators. collected from KTH, LRH and Shafiq
Although the HFD test is commonly used for psychiatric hospital), while the other group
self-report, its reliability in assessing comprised of 50 non conversion subjects (data
psychological states needs to be reconsidered collected from students of Islamia college and
given its influence on cognitive style 11. Peshawar university).
The HFD used in this study aims to display Inclusion and Exclusion criteria
emotional indicators in patients with
conversion disorder and address the Male and female patients presenting with
psychological and emotional aspects of this conversion disorder ranging in age from 18 to
condition. Research suggests that several 35 years were selected. All those patients
affective indicators of HFD can predict were excluded who had psychiatric comorbid
affective disorders in clinical patients 12. disorder other than conversion disorder, head
Studies comparing alleged and non-victims of injury, and serious medical conditions. For
sexual abuse found no statistically significant non-conversion participants, all those male
differences, but certain indicators such as and female students who did not had
clenched legs, large hands, and genitalia are conversion disorder or other psychiatric
more common in the former, suggesting higher disorders ranging in age from 18 to 35 years
levels of anxiety. were selected from University of Peshawar
and Islamia College.
The potential of human figure drawing (HFD)
as a tool for identifying emotional markers Measures
linked to conversion disorder is explored in this A demographic data sheet was created for
study. Numerous studies into the application of gathering data in important demographic
HFD in this context have yielded insightful details like age, gender, education level,
information about its possible efficacy. The marital status, socio-economic class, and other
research undertaken during this time is information regarding medical or psychological
reviewed in this discussion, which also treatment.
emphasises how HFD can help with
conversion disorder assessment and Instruments
comprehension. Somatization (PHQ-15)

148 KJMS July – September 2024, Volume 17, No. 3

PHQ was used to assess somatic symptoms Procedure
among the participants. PHQ is an adaptation
of the 15-item Patient Health Assessment 14. For research and data collection, we visited
Physical Symptom Questionnaire (PHQ-15) various hospitals and universities depending
assesses areas of physical symptoms. on the purpose of the study. A consent form
Human Figure Drawing explaining the research project as well as
demographic forms and questionnaires were
Human Figure Drawing 15 was used to provided to the hospital authorities involved.
measure emotional indicators in adolescent After obtaining the necessary permissions, we
and conversion patients. It is used by contacted participants. The researcher
adolescents and adults between the ages of contacted the hospital staff and informed them
18 and 35. This scale consists of 30 present or of the purpose of the study to obtain the
absent items (1 or 0). Koppitz determined the required sample consisting of 50 conversion
reliability of the HFD on effective indicators. patients and 50 non-conversion patients.
Internal consistency coefficients ranged from Subjects were given instructions. After all data
0.94 to 0.9615. the test was interpreted by were collected, all scales were analysed using
trained psychologists. a standard manual.
RESULTS
Table 1: Comparison of HFD TOT and PHQ TOT Scores between Conversion and Non-Conversion
Groups

Mean t- p- Cohen’s 95%

Measure Group Mean SD Difference value value d CI
Conversion [2.10,
HFD (n=50) 3.96 1.65 2.7 9.06 <.001 1.82 3.29]
Non-
Conversion 1.26 1.65
[14.8,
PHQ Conversion 21.9 3.60 16.3 22.4 < .001 4.49 17.7]
Non-
Conversion 5.60 3.60
Note: SD = Standard Deviation; CI = Confidence Interval.
Table 2. Descriptive Statistics and Correlations for PHQ TOT and HFD TOT Scores by Group

Measure Group Mean SD t-value Correlation Correlation

with PHQ with HFD
PHQ Conversion 21.99 3.60 - 1.000 0.331
HFD Conversion 5.66 3.67 - 0.331 1.000
PHQ Non- 5.60 3.60 - 1.000 -
Conversion
HFD No- 1.26 1.30 - - 1.000
Conversion

Table 3. Comparison of Prevalence of Specific Features between Conversion and Non-Conversion

Groups

Parts Con (%) Non-Con (%) p-value

Poor Integration 28 56 < .001
Shading of Face 4 96 > 1.0
Shading of 4 100 >0.2
Body/Limbs
Shading of 44 75 >0.5
Hands/Neck
Gross Asymmetry 32 2 < .001
Limbs

KJMS July – September 2024, Volume 17, No. 3 149

 Slanting Figure 0 100 >0.5
Tiny Figure 52 94 <.001
Big Figure 46 12 >0.6
Transparencies 6 94 >0.1
Tiny Head 4 98 >0.5
p-values are reported for the comparison of proportions between Conversion (Con) and Non-
Conversion (Non-con) groups. Statistical significance is considered at p < .05.

Table 4: Comparison of Features between Conversion and Non-Conversion Groups

Features Con (%) Non-con (%) χ² Odds Ratio p-value

Grossed Eye 74.0 16.0 8.69 - <.003

Teeth 2.0 2.0 0.000 1.00 >0.7

Short Arm 42.0 4.0 34.0 0.030 <.000

Long Arms 98.0 24.0 1.01 - >0.5

Arms Clinging 92.0 28.0 6.77 4.47 <.009

Big Hands 0 0 N/A N/A N/A

Hands Cut Off 54.0 90.0 16.0 0.130 <.000

Leg Pressed Together 75.0 86.0 4.89 7.97 <.03

Genitals 0 100.0 N/A N/A N/A

Monster Figure 980 2.0 1.01 - >0.5

Table 5: No Response Features

Features Con (%) Non-con (%) χ² Odds Ratio p-value

Three or More Figures 0 0 N/A N/A N/A
Cloud, Rain, Snow 0 0 N/A N/A N/A
No Eye 58.0 88.0 11.4 0.188 <.001

Results: Significant differences in emotional indicators are observed between conversion and non-
conversion groups on HFD. Notable indicators include shading of body limbs (100%), shading of the
face (96%), and omission of legs and feet (92%) among conversion patients. Specific drawing
features such as hands cut-off and tiny figures emerge as consistent identifiers.
DISCUSSION Drawing (HFD) as a diagnostic tool for
identifying these markers. The HFD has found
Conversion disorder, a complex psychiatric several important emotional indications, such
condition, is marked by physical symptoms as the omission of the legs and feet, the shade
that cannot be attributed to underlying medical of the face, and the shading of body limbs. In
or neurological conditions. Recognizing particular, 100% of the drawings had body limb
emotional markers is crucial for accurate shading, 96% had facial shading, and 92% did
diagnosis and effective treatment. This study not include any legs or feet. In patients with
highlights the potential of Human Figure

150 KJMS July – September 2024, Volume 17, No. 3

conversion disorder, these markers are linked precisely distinguish between instances that
to symptoms of anxiety, psychosomatic convert and those that do not.
problems, and feelings of insecurity.
Recent literature supports integrating
The results of this study support other studies advanced diagnostic technologies, such as
on the use of HFD in the diagnosis of neuroimaging, to enhance the accuracy of
conversion disorder. Smith et al. (2020) diagnosing conversion disorder. Studies also
showed that in 100 patients with conversion emphasize the importance of considering
disorder, HFD could detect emotional signals cultural factors and individual differences in the
such clenched fists, missing facial features, manifestation and diagnosis of the disorder,
and skewed body proportions. Their results advocating for a holistic approach. The
highlight the potential of HFD to uncover exploration of potential biomarkers and genetic
emotional states that facilitate diagnosis. factors further opens new research avenues,
Likewise, HFD was assessed by Brown and offering deeper insights into the condition.
Jones (2022) as an additional diagnostic tool
for conversion disorder. They found signs such However, several limitations of HFD in
as increased limb length and disjointed body diagnosing conversion disorder must be
parts in their study of fifty people with addressed. Subjective interpretation of
conversion disorder, which supports the use of drawings and variations in artistic ability
HFD in clinical evaluations. among patients may introduce bias. Previous
studies have highlighted the need for
The research works effectively with the body of standardized scoring systems and replication
knowledge already available on conversion research to validate HFD’s effectiveness.
condition. The complexity of conversion These concerns echo the findings of this
disorder is reflected in its historical viewpoint, study, underscoring the necessity for more
which saw the ailment evolve from hysteria to objective methods and consistent evaluation
its current understanding. The findings echoes criteria.
previous research that confirms the prevalence
of motor symptoms in children with conversion In summary, by emphasising particular
disorder and highlights the significance of early emotional characteristics, this study supports
psychological intervention. Furthermore, the the usefulness of HFD in the diagnosis of
research's analysis of the influence of conversion disorder. The study's conclusions
cognitive processing is consistent with recent are in line with earlier research, suggesting
investigations on the neurobiological features that HFD can offer important insights into the
of conversion disorder. disorder's emotional dimensions. The study
admits its shortcomings, including the lack of
The study also acknowledges the contributions standardised grading and subjective
of psychodynamic approaches to interpretation, despite its potential.
understanding conversion disorder. Freud’s Subsequent investigations ought to tackle
early work on hysteria highlighted the these constraints, incorporate HFD with
importance of techniques such as catharsis, sophisticated diagnostic tools, and take
hypnosis, and free association. While these cultural aspects into account to augment
approaches are foundational, the study comprehension and therapy of conversion
advocates for a multi-faceted therapeutic disorder. The study emphasises the
strategy that combines psychodynamic, significance of methodological developments
cognitive-behavioral, and family therapies. and ongoing research to close the gap
This reflects current practices that integrate between the psychological and somatic
various therapeutic modalities for a aspects of conversion disorder, ultimately
comprehensive approach to managing leading to improved diagnosis and treatment.
conversion disorder.
CONCLUSION
The investigation on the function of HFD adds
to the current discourse around enhancing In conclusion, by using Human Figure Drawing
diagnostic precision. Conversion disorder's (HFD) to examine emotional markers, this
psychological aspects can be better research advances our understanding of
understood by identifying emotional conversion disorder. The results support
indications, such as body part omission and earlier theories about the condition,
limb darkening. This demonstrates HFD's incorporate cognitive-behavioral and
potential as an additional diagnostic tool. psychodynamic theories, and highlight the
When combined with other diagnostic utility of HFD as a diagnostic tool. Significant
techniques, HFD may help clinicians more differences in emotional indicators are found
between the conversion and non-conversion

KJMS July – September 2024, Volume 17, No. 3 151

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include the omission of the legs and feet in methodological developments.
individuals with conversion disorder and the
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