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April 2019, Volume 69, Issue 4

Letter to the Editor

Comment on Lubna Kanwal Dar et al ( J Pak Med Assoc 2018; 68: 1776-81) Traumatic experiences and dissociation in patients with conversion disorder

Laneita Freeman Williamson  ( Department of Rehabilitation Service Line, Wake Forest Baptist Medical Center, Medical Center Blvd, Winston Salem, North Carolina 27157 USA )
Ahmad Zaheer Qureshi  ( Department of Physical Medicine and Rehabilitation, King Fahad Medical City, Riyadh Saudi Arabia 11525 )

In the article by Dar LK regarding patients with conversion disorder, authors have brought awareness to the pervasiveness of childhood adversities and adult health risks in Pakistan. 1 The findings of this research were similar to Adverse Childhood Experience (ACEs) study which also demonstrated a positive correlation between the age of trauma and level of dissociation in adulthood. 2  There are certain limitations in the study by Dar LK. It is gender specific and has a small sample size; however, the authors validate the significance of childhood adversity and recommend a more thorough assessment of patients in order to develop the most appropriate treatment plan. In recent years, the subject of childhood adversity has gained serious attention of the Center of Disease Control and Prevention (CDC) and the World Health Organization (WHO). The significance of this issue is also reflected in published literature, ongoing researches and changes in clinical practice. 3  It is important to cite one of the largest studies done on childhood adversity. 2  CDC and Kaiser Permanente collaborated in the ACEs study, which demonstrated a correlation between ten adversities in childhood and adult health risks. This study was a retrospective and prospective study of over 17,000 patients completed in two waves of data collection. The childhood adversities included were: physical, sexual, and emotional abuse, domestic abuse, physical and emotional neglect,  household dysfunction, mental illness, substance abuseand divorce. 4  The study showed that the pervasive adversities occurring during growth and developmental phases disrupted the architecture of the brain resulting in lifelong neurodevelopmental consequences. These neurodevelopmental outcomes created social, emotional, and cognitive impairments which led to adult health issues and diseases, even in the absence of acquired health risks behaviors. ACE study showed a negative correlation between socioeconomic status and the number of adversities. Subsequently, high number of childhood adversities was associated with increased risks for psychological, behavioral, social, and poor health outcomes in adulthood. The WHO has adopted the Adverse Childhood Experience International Questionnaire, providing introductory materials, a guide for administration, and a questionnaire that can be utilized in all countries.2 However, this questionnaire requires validation in different health setups due to variations in psychosocial, cultural and other health care attributes. Additional retrospective and prospective longitudinal studies of victims of adversities are needed to determine if there is a neurobiological basis to functional neurological disorders, such as conversion disorder. This may be achieved by utilizing the ACEs questionnaire for local studies in Pakistan.
Disclaimer: None to declare.
Conflict of Interest: No conflict of interest to declare.
Sources of Funding: No source of funding to declare.​​​​​​​


1. Dar LK, Hasan S. Traumatic experiences and dissociation in patients with conversion disorder. J Pak Med Assoc 2018;68(12):1776-1781.
2. World Health Organization. Violence and Injury Prevention. Adverse Childhood Experiences International Questionnaire (ACE-IQ). Geneva: 2018 WHO. [Accessed 23 December 2018]. Available from U RL: https :/ /w ww.wh o.i nt/violence _i njur y_preve ntion/ violence/ac tivities/adverse_ childhood_experiences/en/
3. Schalinski I, Teicher MH, Nischk D, Hinderer E, Müller O, Rockstroh B. Type and timing of adverse childhood experiences differentially affect severity of PTSD, dissociative and depressive symptoms in adult inpatients. MC Psychiatry 2016; 19;16:295.
4. Herzog JI, Schmahl C. Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Front Psychiatry 2018; 9:420.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: