Conversion disorder

Alternative name: Hysterical neurosis

Conversion Disorder is a DSM-IV diagnosis which describes neurological symptoms such as weakness, sensory disturbance and attacks that look like epilepsy but which can not be attributed to a known neurological disease.
The DSM-IV definition, which is by no means agreed upon by all those working in the field, is as follows:

• One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition.
• Psychological factors are judged, in the clinician's opinion, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual.
• The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
• The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience.
• The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
• The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

The condition has a complex history. These symptoms are also described as functional, non-organic, hysterical, psychogenic, depending on your etiological point of view. In the International Classification of Diseases they are termed Dissociative. Critics who refute the concept of dissociative disorders hold that as Frederick Crews stated "dissociation is the perfect psychoanalytic-style vehicle for creation of a pseudoscience, since there is no way to disprove its existence and recovered memories never need be tested by comparing them with conscious memories. After all, if children dissociate themselves from the experience, one could not expect them to have any memories of the event. " (Frederick Crews, The Memory Wars: Freud's Legacy in Dispute)
A more precise label is Functional Neurological Deficit which research has shown to be a more acceptable term in doctor patient relationships (Stone et al). Stressing as it does the inabilty of tests to explain the symptom or symptoms. As neurologists depend upon inconsistency for diagnosis there can be tension with colleagues in mental health "When I send a patient to a consultant psychologist I'm told there is nothing wrong with them, that's why I send them to a psychiatrist he always finds something wrong"- Dr. P. Nichols. Such disagreement appears to be common.

That there should be a temporal relationship between symptom onset and some external event of psychological conflict is a question of debate. There has been a long history of symptoms misdiagnosed as having no underlying physical cause. In women, the term Female hysteria was used to refer to a wide spectrum of symptoms ranging from fainting to anxiety. As a term it goes back over 2000 years and was thought to relate to abnormal motions of the uterus. From the 17th century onwards, Thomas Willis, Robert Whytt and others increasingly realised the problem was in fact localised to the brain and mind.

In the 19th century, physicians such as Silas Weir Mitchell in the US and Paul Briquet and Jean-Martin Charcot in France developed ideas about patients with these neurological symptoms which would now be classed as neuropsychiatric. Charcot specialized in treating patients who were suffering from a variety of unexplained physical symptoms including paralysis, contractures (muscles which contract and cannot be relaxed) and seizures. Some of these patients sporadically and compulsively adopted a bizarre posture (christened arc-de-cercle) in which they arched their body backwards until they were supported only by their head and their heels.

"Charcot eventually came to the conclusion that many of his patients were suffering from a form of hysteria which had been induced by their emotional response to a traumatic accident in their past – such as a fall from a scaffold or a railway crash. They suffered, in his view, not from the physical effects of the accident, but from the idea they had formed of it... However many of the most basic diagnostic techniques which are taken for granted by modern physicians had still to be discovered. The lumbar puncture, which is the only way in which Breuer could have tested his momentary hunch that Anna O. was suffering from meningitis, was not developed until 1891, and was not in general use until the early part of the twentieth century. X-rays, which would eventually become one of the most useful of all diagnostic aids, were discovered only in 1895 – the same year in which Studies on Hysteria was published. The electroencephalogram, which would revolutionize neurology and psychiatry and lead to the final definition of temporal lobe epilepsy, was not invented until 1929, and was not in general use until the 1940s. Many other basic techniques of neurological investigation would not be developed until even later. The computed tomography scan, for example, which uses X-ray transmission readings to generate an image of the brain and which can display some lesions, tumors and other signs of pathology directly, began to be generally used only in the late 1970s. Not only were these diagnostic techniques unavailable to Breuer, Freud and their contemporaries, but neurology and psychiatry were relatively young and under-organized branches of medicine whose stores of knowledge were only just beginning to be built up." (Webster, Why Freud Was Wrong).
It is also now recognised that many of Charcot's demonstrations of hysteria were faked (Szasz, the Myth of Mental Illness). As many neurologist's remain ignorant of Charcot's methodology at the Salpκtriθre in the diagnosis of hysteria he is often held up as a champion of neuropscyhiatry (Stone et al). It is doubtless though that as neurology continues to emerge from diagnostic darkness further techniques are likely to be developed and previously unvisualized abnormalities and conditions recognized.

The term "Conversion disorder" is a legacy of Freud and the psychotherapy movement. He viewed these apparently neurological symptoms as a result of the conversion of intrapsychic distress in to physical symptoms. It is worth bearing in mind that much of Freud's work is now viewed with scepticism, and it may be that patients Freud thought were hysterical may actually have suffered from organic illness, such as "Anna O." (see Alison Orr-Andrewes, "The case of Anna O: A Neuropsychiatric perspective" in Journal of the Psychoanalytic Association 1987, vol 35 p.399).

In the 1960s the London Psychiatrist Eliot Slater recognized that finding a life event just before the onset of a symptom was an entirely unreliable way of diagnosing conversion disorder.

“Unfortunately we have to recognize that trouble, discord, anxiety and frustration are so prevalent at all stages of life that their mere occurrence near to the time of onset of an illness does not mean very much.” — Eliot Slater

He also suggested that conversion disorder was largely a 'delusion and a snare' since many of the people said to have it would eventually go on to develop a neurological disease that in hindsight could explain their original symptoms. This echoed the earlier sentiments of Steyerthal: "Within a few years the concept of hysteria will belong to history ... there is no such disease and there never has been. What Charcot called hysteria is a tissue woven of a thousand threads, a cohort of the most varied diseases, with nothing in common but the so-called stigmata, which in fact may accompany any disease." — Armin Steyerthal (1908)

Studies since 1970 have shown that misdiagnosis still occurs but at a rate of around 5% which is the same as for other neurological and pscyhiatric symptoms (Stone et al BMJ 2005). Whether this is a social phenomenon produced by the modus operandi of health care systems requires further research. Most patients only receive investigations at the onset of illness and many illnesses, such as MS, are hard to diagnose initially. Patients also tend to produce functional symptoms in response to the disbelief and prompting of a neurologist as Slater also recognized. Inconsistency could thus be seen as merely an expression of self-consciousness and desperation in the light of distressing symptoms. It is interesting in this light to note however that 20% of MS patients are re-classified as having functional symptoms and there is a high co-morbidity of functional symptoms alongside recognized organic brain disease.

Historically, conversion disorder was thought to manifest itself in many different ways. Conversion disorders were thought to be triggered by acute psychosocial stress that the individual could not process psychologically. This overwhelming distress was thought to cause the brain to unconsciously disable or impair a bodily function which would relieve or prevent the patient from experiencing this stressor again. This is in stark contrast to the modern understanding that patients remain distressed by their symptoms in the long term (Stone et al JR Soc Med 2005; 98:547-548) and generally any hypothesized stressor is removed temporally and symbolically from the onset of symptoms. Therefore, the psychosocial stress cannot be seen to be "converted' into a physical symptom that relieve suffering, when in actual fact they increase it. Historically, the patient, by definition, was considered to be unaware of this process, and often not concerned with his deficit — a feature called la belle indifference. Research now shows this to be untrue (Stone et al as above).

More recently, research is attempting to examine the complex nature of these symptoms and the absurdity of a dualist approach which attempts to suggest that symptoms are either all organic or all psychiatric. Functional neuroimaging has shown intriguing findings with respect to the neural correlates of these symptoms (best example is Vuilleimier et al Brain Vol. 124, No. 6, 1077-1090, June 2001)

Conversion disorder can present with any motor or sensory symptom in the body including:
• Weakness / Paralysis of a limb or the entire body hysterical paralysis or motor conversion disorders
• Impaired hearing or vision
• Loss / Disturbance of sensation
• Impairment or loss of speech--- hysterical aphonia
• Psychogenic non-epileptic seizures
• Fixed Dystonia unlike normal dystonia
• Tremor, Myoclonus or other movement disorders
• Astasia-abasia or Gait Problems
• hysterical pregnancy (even though though this is common in other mammals to ensure enough milk for the group's offspring)

Diagnosis depends not on the absence of findings of neurological disease but on the finding of positive evidence of conversion symptoms.
La belle indiffιrence has been described as a characteristic feature of conversion. It is characterized by the inappropriate and paradoxical absence of distress despite the presence of an unpleasant symptom. Patients often deny emotional difficulty. Traditionally associated with conversion disorder, la belle indiffιrence, histrionic personality, and secondary gain are clinical features that appear to have no diagnostic significance. Although presence of these features supports the diagnosis, they have no diagnostic validity because the diagnosis of conversion disorder ultimately depends upon clinical findings that clearly demonstrate that the patient's symptomatology is not caused by organic disease.

One study reported 5 patients with hysterical conversion reactions after injury or infarction to the left cerebral hemisphere. [3]
Conversion symptoms are remarkably consistent between patients, just as Parkinson's disease is consistent between patients. There may be positive evidence of patterns of weakness (for example Hoover's Sign or a non-pyramidal pattern of weakness) or a typical gait problem (for example a 'dragging monoplegic gait). For Psychogenic non-epileptic seizures a range of features of the attacks must be taken in to consideration and the diagnosis may need confirmation with videotelemetry.

Diagnosis is not easy and should preferably only be made by a neurologist with experience of the condition.
Patients with conversion symptoms will typically have multiple other symptoms which may include fatigue, sleep disturbance, memory and concentration difficulties, pain (neck, back, muscles), bowel and bladder sensitivity

Prevalence: In the US: True conversion reaction is rare. Predisposing factors, according to the DSM-IV, include prior physical disorders, close contact to people with real physical symptoms, and extreme psychosocial stress. In the United Kingdom however 40% of neurological referrals are deemed to be suffering from conversion disorder (Stone, Carson & "Wessely School" psychiatrists)
Incidence has been reported to be 15-22 cases per 100,000 people. In patients with chronic pain, incidence was 0.22%. Conversion reaction may occur more often in rural settings, where patients may be naive about medical and psychological issues. In one study, high rates were seen in Appalachian males. The disorder is observed more commonly in lower socioeconomic groups and may be more common in military personnel exposed to combat situations.

Cultural factors may play a significant role. Symptoms that might be considered a conversion disorder in the US may be a normal expression of anxiety in other cultures. One study reports that conversion disorder accounts for 1.2-11.5% of psychiatric consultations for hospitalized medical and surgical patients. Internationally: At the National Hospital in London, the diagnosis was made in 1% of inpatients. Iceland's incidence of conversion disorder is reported to be 15 cases per 100,000 persons.

Sex ratio is not known although it has been estimated that women patients outnumber men by 6:1. Many authors have related the development of conversion disorder in women with sexual maladjustment. Other authors disagree, stating that men are as likely to experience conversion symptoms as women. Men seem to be especially prone if they have suffered an industrial accident or have served in the military. In a study at the University of Iowa conducted from 1984-1986, patients diagnosed with conversion disorder were in large part men, especially those with a history of military combat.

Studies report that 64% of patients with conversion disorder show evidence of an organic brain disorder, compared with 5% of control subjects. Some bacterial pathogens can also mirror conversion symptoms and non-pyramidal weakness as they alter brain chemistry and function rather than structure (forthcoming publication). However testing, especially in the United Kingdom, remains primitive with only dark field microscope studies providing conclusive evidence of spirochete infection. Progress in the States is much more advanced which could explain the discrepancy in diagnostic rates. An earlier study revealed that a medical explanation eventually emerged from presenting chief complaints in only 7% of patients. Incidence of true neurological disease discovered at a latter date is extremely rare, largely due to advances in diagnostic testing.

The Extent to Which Age and Life Experiences Influence Incidence
Conversion disorder may present at any age but is rare in children younger than 10 years or in persons older than 35 years. Some studies have reported another peak for patients aged 50-60 years. In a University of Iowa study of 32 patients with conversion disorder, however, the mean age was 41 years with a range of 23-58 years. In pediatric patients, incidence of conversion is increased after physical or sexual abuse. Incidence also increases in those children whose parents are either seriously ill or have chronic pain.

Often a patients reaction to the diagnosis of conversion disorder is to be offended that the doctor thinks they are crazy or making their symptoms up. It is true to say that many doctors still do regard these symptoms as 'not genuine' and not deserving of attention. However, many doctors do regard them as genuine but struggle to know how to communicate with patients If patients with conversion symptoms were malingering there would be a number of problems from clinical practice to sort out:
• Evidence from long term studies showing that symptoms persist at follow up many years later
• Patients with conversion symptoms generally desire tests, malingerers would not
• There is remarkable consistency between patients (who have not met each other)

Treatment may include the following
1. Explanation - This must be clear and coherent. It must emphasise the genuineness of the condition, that it is common, potentially reversible and does not mean that the sufferer is a 'psycho'. Taking an aetiologically neutral stance by describing the symptoms as functional may be helpful but further studies are required. Ideally the patient should be followed up neurologically for a while to ensure that the diagnosis has been understood
2. Physiotherapy where appropriate
3. Treatment of comorbid depression or anxiety if present
There is little evidence based treatment of conversion disorder (Ruddy and House - Cochrane Collaboration). Other treatments such as cognitive behavioural therapy, hypnosis, psychodynamic psychotherapy need further trials. It should also be noted that psychoanalytic treatments, on which CBT is based, were singularly unaffective with Freud and Breuer's patients.

Generally, onset of symptoms is linked to a socially or psychologically stressful event. The symptom must be clinically significant; ie, it must be distressing enough to disrupt the patient's social, occupational, or other important area of functioning. A patient may have a single episode or sporadic ones; usually, episodes are brief. When hospitalized, patients with conversion symptoms generally improve within 2 wk; however, 20 to 25% have recurrences within a year, and in some, symptoms become chronic.

The diagnosis may be difficult initially because the patient believes the symptoms stem from a physical disorder. Also, physicians are taught almost exclusively to consider (and exclude) physical disorders as the cause of physical symptoms. Commonly, the diagnosis is considered only after extensive physical examinations and laboratory tests fail to reveal a disorder that can fully account for the symptom and its effects. Although ruling out a possible underlying physical disorder is crucial, early consideration of conversion may avoid tests that increase the costs and risks to the patient and that may unduly delay diagnosis. The best clue is that conversion symptoms rarely conform fully to known anatomic and physiologic mechanisms.

Treatment is recommended to help the person understand the underlying psychological conflict. The integrity of the affected body part or function must be maintained until the conflict is resolved and the symptoms usually disappear. For example, paralyzed limbs must be exercised to avoid muscle wasting.

Symptoms usually last for days to weeks and may resolve spontaneously. Usually the symptom itself is not life-threatening, but the development of complications as a result of the symptom can be debilitating. A trusting physician-patient relationship is essential. After the physician has excluded a physical disorder and reassured the patient that the symptoms do not indicate a serious underlying disorder, the patient usually begins to feel better and symptoms fade. When a psychologically distressing situation has preceded symptom onset, psychotherapy can be effective. Various treatments have been tried, but none is uniformly effective. In hypnotherapy, the patient is hypnotized, and potentially etiologic psychologic issues are identified and explored. Discussion continues after hypnosis, when the patient is fully alert. Narcoanalysis is similar to hypnosis, except that the patient is given a sedative to induce a state of semisleep. Behavior modification therapy, including relaxation training, is effective in some patients.

Examples of conversion symptoms include blindness, diplopia, paralysis, seizures, anesthesia, aphonia, amnesia, unresponsiveness, and difficulty walking. Conversion disorder represents one type of somatoform disorder. The essential element of all somatoform disorders is the presence of physical symptoms or signs that cannot be explained by a medical condition. Unlike factitious disorders and malingering, the symptoms of somatoform disorders are not intentional or under voluntary control.

It has been postulated that the patient derives primary and secondary gain. With primary gain, the symptoms allow the patient to express the conflict that has been suppressed unconsciously. With secondary gain, symptoms allow the patient to avoid unpleasant situations or garner support from friends, family, and the medical system that would otherwise be unobtainable. According to sociocultural theories, the direct expression of emotions is impermissible and somatization takes its place. In behavioral models, conversion symptoms are viewed as a learned maladaptive behavior that is reinforced by the environment.

The idea that conversion disorder does not have an organic basis has become entrenched. However, some evidence supports the opposite notion. Studies on the natural history of conversion disorder indicate that many patients subsequently develop or are found to have preexisting neurological disease. In fact, conversion disorders may be more frequently observed in patients with a past history of a central nervous system injury. The simultaneous occurrence of organic brain disease with conversion symptoms also is observed, most notably in observation of high rates of organic seizure syndromes associated with psychogenic nonepileptic seizures. Familial studies have also shown that conversion symptoms in first-degree female relatives are up to 14 times greater than in the general population.

• In the US: Stefansson et al report that the annual incidence of conversion reactions is 22 cases per 100,000 persons per year in Monroe County, New York. However, the reported rates vary widely. In a study of 100 consecutive women following a normal full-term pregnancy, 33 were noted to have a past history of conversion symptoms. In a study of 100 randomly selected patients from a psychiatry clinic, 24 were noted to have unexplained neurological symptoms. It is reported to be more common in rural populations, in individuals with lower socioeconomic status, and in individuals with less medical knowledge.
• Internationally: Stefansson et al report that the annual incidence is 11 cases per 100,000 persons per year in Iceland.
Mortality/Morbidity:
• Individual conversion symptoms generally are self-limiting and do not lead to physical changes or disabilities.
• Morbidity is often an iatrogenic manifestation of unnecessary diagnostic or therapeutic interventions.
• Patients with chronic conversion symptoms (rarely) may develop atrophy, frozen joints, and contractures from disuse.
Sex:
• The female-to-male ratio is 2-10:1.
Age:
• The typical onset is between the second and fourth decades.
• The reported range is from children to individuals in their ninth decade of life.


• Patients with conversion disorder may present with hemiparesis, paraparesis, monoparesis, alteration of consciousness, visual loss, seizurelike activity, pseudocoma, abnormal gait disturbance, aphonia or dysphonia, lack of coordination, or a bizarre movement disorder. Patients who are more medically naοve typically have more implausible presenting symptoms. The presenting symptoms depend on the cultural milieu, the degree of medical sophistication, and the underlying psychiatric issue.
• Patients with conversion disorder typically deny any emotional problem and resist a consultation with a psychiatrist. Therefore, responsibility lies with other medical personnel to perform the initial management prior to conveying the diagnosis.
Physical: A full physical examination with attention to the mental status (indifferent affect) and neurological examination should be performed. Certain principles are used during the neurological examination to distinguish psychogenic deficits from neurological ones. The pattern of deficits usually does not conform to known anatomic pathways. For example, patients who present with monoparesis will not have weakness in a corticospinal tract or neuropathic or a myopathic distribution. In addition, no changes may be seen in reflexes or tone that typically would be expected.

The physician should contrast formal examination from functional observations. Patients who do not move a limb when asked on examination may be observed to use that limb inadvertently while dressing or talking. Patients who do not dorsiflex the foot while seated may walk on the heels when asked to do so. Another example might be a patient who cannot stand on one leg who may be observed to do so while putting on pants.

Observations when the patient is unaware of being examined are helpful. Patients with psychogenic movements may have no such movements when observed in the waiting room. Multiple examinations by one or more practitioners may disclose variable results. However, caution is necessary when applying these rules. No single feature is absolute. The knowledge pertaining to neuroanatomy and the clinical deficits that arise from abnormalities is not completely known, thus resulting in limitations of the neurological examination. In addition, patients can embellish on organic deficits. Therefore, only a presumptive diagnosis can be made after the initial evaluation.

Further complicating the assessment is the knowledge that up to 30% of patients with conversion disorder develop a physical illness that may account for their symptoms if followed longitudinally. It also is not uncommon for patients with conversion disorder to have a comorbid medical or neurological illness. An example is the patient who exhibits both epileptic seizures and psychogenic nonepileptic seizures, a clinical situation not uncommon to epilepsy referral centers.

Other specific details to help diagnose 3 different conversion symptoms include the following:

• Psychogenic hemiparesis

• Unilateral weakness or hemiparesis is one manner in which the patient with conversion disorder may present.

• Classic hemiparesis represents a deficit of the corticospinal tract. In an acute lesion of the corticospinal tract, a patient may demonstrate flaccidity of the weak limbs, which is associated with decreased reflexes. In more chronic lesions, the patient may develop spasticity of the affected limbs, hyperreflexia, and an extensor toe sign (positive Babinski). The patient with hemiparesis from a corticospinal tract lesion may demonstrate weakness of the extensor muscles to a greater extent than the flexor muscles and may show greater weakness distally than proximally.

None of these findings would likely be seen in the patient with conversion disorder. In psychogenic hemiparesis, the muscle contractions are poorly sustained and may weaken abruptly as the patient resists the force exerted by the examiner. This is felt clinically as a "give-way" or ratchet-like weakness, unlike the fluid weakness throughout the range of motion usually felt by the examiner in an upper or lower motor neuron lesion.

The Hoover sign also may be elicited. When a patient in the recumbent position flexes the thigh and lifts the leg, the downward movement of the contralateral leg is automatic. The examiner places a hand beneath the heel and asks the patient to raise the paretic leg. In feigned weakness, no appreciable downward movement is evident. In addition, when the patient is asked to raise the normal leg, the downward movement is appreciated from the "paretic" leg.

 Another helpful tool is examining the sternocleidomastoid muscle. Normal contraction of this muscle results in the face rotating in the opposite direction. The patient with psychogenic weakness therefore may display weakness of the contralateral sternocleidomastoid (ie, weakness in turning the face towards the hemiparetic side).
Recognizing the patient with psychogenic hemiparesis includes observing the following:
 No changes in reflexes
 No changes in tone
 Give-way quality of weakness
 Extensor and flexor muscles equally weak
 Contralateral sternocleidomastoid weakness
 Positive Hoover sign
 Difference between formal examination and general observations
 

Psychogenic nonepileptic seizures
o Distinguishing between a psychogenic nonepileptic seizure, or pseudoseizure, and an epileptic seizure is challenging. The manifestations of each are diverse, and the clinical diagnosis rests on historical information from witnesses with varying observational skills. Simultaneous video electroencephalogram (EEG) monitoring has significantly improved the accuracy of diagnosis, but this technique is expensive and not routinely available. Psychogenic seizures may constitute up to 20% of all patients in an epilepsy referral center. Refer to the article on Psychogenic Seizures in the eMedicine Neurology section for more details.
 

Classic clues that suggest nonepileptic seizure include the following:
 Ineffectiveness of multiple antiepileptic drugs
 Induced by stress or emotional upset
 Lack of physical injury
 Lack of headache or myalgias following convulsions
 Lack of incontinence
 Biting the tip of the tongue as opposed to the side or the lip
 History of sexual or physical abuse
 Signs or symptoms suggestive of another conversion
 Memory of a generalized ictal event
o Ictal characteristics that suggest nonepileptic seizure include the following:
 Gradual onset of ictus
 Prolonged duration (>4 min)
 Atypical or excessive motor activity such as thrashing, rolling from one side to the other, pelvic thrusting, or arrhythmic (out-of-phase) jerking such as alternating side flexion and extension of the arms
 Waxing and waning amplitude
 Intelligible speech
 Bilateral motor activity with preserved consciousness
 Clinical features that change from one spell to the next (ie, nonstereotyped)
 Lack of postictal confusion
 Postictal crying or cursing
 Directed violent acts
 Eyes closed during the ictus
 Resistance to eye opening
 Purposeful resistance to passive movements
 

Psychogenic movement disorders
o Conversion disorder can imitate the entire spectrum of movement disorders and include tremor, chorea, myoclonus, dystonia, tics, parkinsonism, and a host of bizarre gait disturbances. A commonly used term for a type of this last phenomenon is an astasia-abasia gait pattern, in which the patient will make wild movements of the trunk and arms during a gait evaluation but does not fall or err from a stressed gait such as a tandem or toe gait.
 

Clinical symptoms or signs that may help distinguish psychogenic movements from organic ones include the following:
 Abrupt onset of symptoms
 Character of movements atypical of recognized patterns and have inconsistent amplitude, frequency, and distribution
 Characteristics of movements change over time
 Entrainment of the tremor to the rate requested by the examiner
 Spontaneous remissions
 Movements disappear with distractions
 Movements increase with attention
 Response to placebo, psychotherapy, or suggestion
 Paroxysmal symptoms
 Nonobjective weakness or sensory changes also present
 Obvious secondary gain (eg, litigation, health insurance claim, military service)
 

Causes:
• Neuroimaging studies of conversion disorders indicate hypofunction of the dominant hemisphere and a consequent overactivity in the nondominant side. Other neuroanatomic findings have been seen with conversion disorder. Marshall et al reported changes in regional cerebral blood flow (rCBF) in a female patient with a left leg paralysis and intact sensory modalities for which no anatomic cause of her weakness could be found. Attempting to move her paralyzed leg did not show activation of contralateral motor cortex, but rather contralateral orbit-frontal and anterior cingulated cortex were activated. This implied an anatomic inhibition of primary motor cortex in one case of hysterical paralysis.
• Neuropsychological testing shows evidence of impaired attention and short-term memory.
• Psychodynamic theory postulates that conversion symptoms are the result of conversion of anxiety regarding an unconscious intrapsychic conflict into somatic symptoms.
• Learning theorists believe that such symptoms develop from conditioning that occurs during childhood and that these learned behaviors arise again when the person is subjected to overwhelming stress later in life.
• Such symptoms also can be viewed as a form of physical communication of an emotionally charged idea or feeling when one is unable to verbalize the conflict because of personal or social taboos.
 

Other Problems to be Considered:
The differential diagnosis of conversion disorders is highly dependent on the manner in which the patient presents. Organic etiologies must be excluded. For example, the differential for psychogenic hemiparesis includes tumor, stroke, multiple sclerosis, and many others.


Lab Studies:
• Hemiparesis
o MRI of brain with diffusion-weighted imaging
o MRI of cervical region

• Pseudoseizure
o MRI of brain
o EEG
o Prolonged video-EEG monitoring
o Provocative EEG with placebo induction
o Echocardiogram
o Holter monitor
o Tilt-table test
o Prolactin level 30 minutes after the event: An elevation above baseline can occur with partial seizures, generalized seizures, or syncope, but not with pseudoseizures.

• Psychogenic movement disorders
o MRI of brain
o Twenty-four–hour urine copper, serum ceruloplasmin, and slit lamp examination for evidence of Kayser-Fleisher rings to look for evidence of Wilson disease
o Thyroid-stimulating hormone, thyroid peroxidase antibodies, thyroglobulin antibodies
o CBC count with smear for acanthocytes
o Erythrocyte sedimentation rate, antinuclear antibody, extractable nuclear antibody, anticardiolipin antibody, lupus anticoagulant
o HIV antibody, Lyme antibody, anti-streptolysin O (ASO) antibody
o Human chorionic gonadotropin
 

Procedures:
• Hypnosis or amobarbital interview
o To ensure diagnosis
o To disclose underlying psychiatric issues
• Brain PET scan - Has demonstrated evidence of left dorsolateral prefrontal cortex hypofunction
• SPECT scan - Has shown decrease in regional blood flow in the thalamus and basal ganglia contralateral to the deficit
TREATMENT Section 6 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography

Current understanding of the phenomenon of conversion disorder implicates some role of the unconscious in the pathophysiology of this condition. It is therefore less likely to respond to treatment when the manifestations of the conversion are confronted directly as a unitary method of therapy. Many patients who experience a conversion disorder are unable to understand this inner conflict, which is perhaps occurring on an unconscious level. They may achieve resolution of the conflict, and their physical symptoms, once they are gently made aware of this connection. Once the patient is aware of this, the psychologic currency of the symptom loses value, and the symptom may be allowed to improve.
• Consider hospital admission: The patient may not return for follow-up after being given a psychiatric diagnosis. A more rapid completion of the diagnostic workup is possible. In addition, a parallel investigation of physical and psychologic factors can and should be pursued. One caveat to note is that the clinical situation may be worsened by providing the patient with the secondary gain he or she is seeking.
• Avoid invasive diagnostic and therapeutic interventions.
• Tactful presentation of the diagnosis to the patient includes the following:
o Avoid giving the patient the impression that you feel there is nothing wrong with them.
o Do not inform the patient of the diagnosis on the first encounter.
o Reassure the patient that the symptoms are very real despite the lack of a definitive organic diagnosis.
o Provide socially acceptable examples of diseases that often are deemed stress-related (eg, peptic ulcer disease, hypertension).
o Provide common examples of emotions producing symptoms (eg, queasy stomach when talking in front of an audience, sweaty palms when asking someone for a date).
o Provide examples of how the subconscious influences behavior (eg, nail biting, pacing).
o Provide reassurance that no evidence of an underlying neurological disorder is present based on the tests that were performed and that the prognosis for recovery is very good.
o Provide positive reinforcement that the symptoms can improve spontaneously.
o Inform patients that the symptoms are not volitional, and no one believes that they are faking.
o Provide a graceful way for the patient to improve from the symptoms. (Allow for the symptom to get better over time, just as an organic entity might improve.)
• No specific pharmacologic therapy is available for conversion disorder; however, medications for comorbid mood and anxiety disorders should be considered. Care should be taken to avoid dependence-producing psychotropic agents.
• Physical therapy may be warranted.
• Institute patient and family education sensitively in order to not make the patient feel worse.
• Regular follow-up appointments with a neurologist or a psychiatrist should be provided to limit ER visits, which may lead to contact with multiple healthcare providers and, in turn, unnecessary diagnostic/invasive tests.
Consultations:
• Neurologist: This is the primary evaluation for differentiating conversion disorders from neurological diseases.
• Cardiologist: Consultation is warranted if the patient has episodic alterations of consciousness.
• Physical therapist: Consultation may be warranted.
• Psychiatrist: This generally is indicated when the symptoms persist. This can aid in identification of psychologic stressors symbolically linked to the symptoms and other risk factors for conversion disorder. The patient must be informed about the consultation before the psychiatrist does the interview. Psychiatric treatments that have demonstrated effectiveness include the following:
• Psychodynamic therapy: Patients with borderline intelligence, lack of motivation or introspection capabilities, important secondary gains, or those with a tendency for behavioral acting out likely are poor candidates.
• Behavioral therapy: The inappropriate behavior no longer is rewarded or may even be punished. An advantage is that neither normal intelligence nor insight is necessary for success. A disadvantage is that behavioral therapy relies on controlling the environmental conditions, which may not be feasible.
• Psychologist: Psychosocial interventions that may be helpful include paradoxical intention therapy and hypnosis.
• Family therapist: Interactions and communication within the family are emphasized rather than only focusing on the individual patient.
FOLLOW-UP Section 7 of 10
Author Information Introduction Clinical Differentials Workup Treatment Follow-up Miscellaneous Pictures Bibliography

Prognosis:
• Spontaneous resolution in most - Approximately 75%
• Recurrence of same or different conversion symptoms - Approximately 25% in 15-year follow-up studies
• False-positive diagnosis of conversion disorder
o Approximately 25% are diagnosed with neurological disease in 10-year follow-up that could account for presenting symptoms.
o Multiple sclerosis, neurodegenerative diseases, structural myelopathy, peripheral neuropathy, and myopathy accounted for the false-positive diagnoses.
• Good prognostic factors - Acute onset of symptoms, short duration of symptoms, healthy premorbid functioning, higher intelligence, absence of coexisting psychopathology, presence of an identifiable stressor
• Poor prognostic symptoms - Pseudoseizure, psychogenic tremor
Patient Education:
• Sensitively review the disorder with the patient and the family in such a way to not make them feel blamed and to not worsen the condition. During such follow up for review of completed imaging and other studies, continuing to emphasize the importance of, as well as your concern for the patient's pain or other symptom is important. The physician may at the same time reassure the patient that the negative test results are good news for their eventual recovery. Frequent office visits to ensure the expected resolution of their symptoms may be helpful.

Medical/Legal Pitfalls:
• Delay in diagnosing organic disease due to lack of appropriate evaluation
• Unnecessary interventional diagnostic tests resulting in iatrogenic illness
• Overly direct or confrontational presentation of the diagnosis, which may entrench the symptom and lead to prolonged patient disability


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