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Conversion Disorder

Neurosis Hysterical Conversion Type

Conversion disorder is a type of somatoform disorder which may occur as an expression of psychological or emotional conflicts. 


Presentation

Conversion disorder involves one or more unexplained physical symptoms. The onset of conversion disorder is usually acute. It may follow a stressful or psychologically traumatic event such as loss of employment, divorce, family dysfunction, or a history of sexual or physical abuse [1] [11].

Some common symptoms of conversion disorder include [1]:

Speech abnormalities and dystonia are thought to be due to the patient’s unconscious manifestation of their inability to speak, express their feelings, and communicate their meaning [6] [13].
Psychogenic gait abnormalities in conversion disorder can present various ways. Sudden buckling of the knees and ataxia are the most common presentation [14].

Psychiatric comorbidity exists with high frequency in patients with conversion disorder. Depression, anxiety disorder, and neurasthenia are the primary psychiatric diagnoses seen [2].

Weight Gain
Abdominal Pain
  • pain without physical findings, hysterical blindness, gait defects, paralysis, sensory loss, seizures, urine retention.[medical-dictionary.thefreedictionary.com]
  • Proving a certain symptom is voluntarily counterfeit is made through direct evidence, whilst ruling out organic etiology. 4 The symptoms most likely include forgery of complaints (abdominal pain, in the absence of pain), self-infliction (ie, injecting[nature.com]
  • Somatisation disorder People with this disorder have many physical symptoms from different parts of the body - for example: Headaches Feeling sick (nauseated) Tummy (abdominal) pain Bowel problems Period problems Tiredness Sexual problems The main symptoms[patient.info]
Vomiting
  • Other motor disturbances that are at times associated with conversion disorder are loss of speech (aphonia), coughing, nausea, vomiting, or hiccuping.[britannica.com]
  • Visceral Symptoms : Examples are trouble swallowing, frequent belching, spells of coughing or vomiting, all carried to an uncommon extreme.[psychnet-uk.com]
Nausea
  • Other motor disturbances that are at times associated with conversion disorder are loss of speech (aphonia), coughing, nausea, vomiting, or hiccuping.[britannica.com]
Hiccup
  • Other motor disturbances that are at times associated with conversion disorder are loss of speech (aphonia), coughing, nausea, vomiting, or hiccuping.[britannica.com]
Recurrent Abdominal Pain
Dermatitis
  • Ozman M, Erdogan A, Aydemir EH, Oguz O: Dissociative identity disorder presenting as dermatitis artefacta. Int J Dermatol 2006;45:770–771. Peterson G: Children coping with trauma: diagnosis of ‘dissociation identity disorder’.[doi.org]
Facial Numbness
  • A' who was experiencing myriad symptoms which included tremors, facial numbness, and severe headaches. She was admitted to a hospital and underwent many tests, which all came back negative.[study.com]
Suggestibility
  • Abstract Conversion disorders often present with dramatic physical presentations suggestive of severe organic disease.[ncbi.nlm.nih.gov]
  • Extreme caution is suggested in regards to further investigations.[ncbi.nlm.nih.gov]
  • The results suggest that motor inhibition in conversion disorder patients is mediated by the IFG that was also involved in inhibition processes in normal subjects.[ncbi.nlm.nih.gov]
  • This suggests a mechanism linking emotions to motor dysfunction in CD.[ncbi.nlm.nih.gov]
  • A proactive approach during the interview, making suggestions the individual will respond, could influence outcome. Comorbid psychiatric disorder should be treated conventionally. Experimental studies to determine efficacy are required.[ncbi.nlm.nih.gov]
La Belle Indifference
  • See 'la Belle indifference. ', Factitious disease, Hysterical neurosis, Post-traumatic stress disorder. con·ver·sion dis·or·der ( kŏn-vĕr'zhŭn dis-ōr'dĕr ) A mental disorder in which an unconscious emotional conflict is expressed asan alteration or loss[medical-dictionary.thefreedictionary.com]
  • La belle indifference (the patient's lack of concern regarding the apparent magnitude of the deficit), once believed to be a hallmark of conversion disorder, is not consistently present.[journalofethics.ama-assn.org]
  • Clinical presentation Subjects suffering from CD might behave in a way known as ‘ la belle indifference ’, a situation in which the patient appears detached from the physical symptoms, that otherwise would have caused him great anxiety.[nature.com]
Psychiatric Manifestation
  • Patients with SS or SLE present with various neurological symptoms and psychiatric manifestations.[ncbi.nlm.nih.gov]
Headache
  • Abstract We report a case of a 14-year-old girl who presented, following a sudden onset, with bilateral ptosis, gait disturbance, difficulty swallowing and loss of appetite, right hypochondriacal pain, and frontal headache.[ncbi.nlm.nih.gov]
  • Everyone has stress, Speed said, and it can be expressed physically in different ways: tension headaches, tight necks, even diarrhea. “I used to have friends in medical school who had to run to the bathroom before exams,” Speed said.[healthcare.utah.edu]
  • Most everyone, for instance, has had a tension headache or an upset stomach. As their descriptions suggest, these conditions are manifestations of emotional stress. Conversion disorders are different and much less common.[instituteforchronicpain.org]
  • A' who was experiencing myriad symptoms which included tremors, facial numbness, and severe headaches. She was admitted to a hospital and underwent many tests, which all came back negative.[study.com]
Paresthesia
  • Sensory disturbances may range from paresthesias (“peculiar” sensations) through hyperesthesias (hypersensitivity) to complete anesthesias (loss of sensation).[britannica.com]
  • […] neurological symptom disorder. conversion disorder an abnormality in which repressed emotional conflicts are changed into sensory, motor, or visceral symptoms with no underlying organic cause, such as blindness, anesthesia, hypesthesia, hyperesthesia, paresthesia[medical-dictionary.thefreedictionary.com]
  • Other common symptoms are anesthesias, paresthesias (particularly of the extremities), deafness, abnormal movements, gait disturbances, weakness, tremors, and seizures (so-called pseudoseizures).[journalofethics.ama-assn.org]
Dysarthria
  • The symptoms include mild dysarthria to coma or sudden death. The initial subtle clinical presentation could lead to misdiagnosis. Psychogenic diagnosis in the differential could make the timely diagnosis more difficult.[ncbi.nlm.nih.gov]
  • Abstract Multiple reports have described patients with disordered articulation and prosody, often following acute aphasia, dysarthria, or apraxia of speech, which results in the perception by listeners of a foreign-like accent.[ncbi.nlm.nih.gov]
Vertigo
  • Diagnosis The differential diagnosis of PNES firstly involves ruling out epilepsy as the cause of the seizure episodes, along with other organic causes of non-epileptic seizures, such as syncope, migraine, vertigo, and stroke, for example.[epilepsyqueensland.com.au]
Dizziness
  • But, stress and other mental health problems can cause many other physical symptoms such as: Chest pains Tiredness Dizziness Back pain Feeling sick (nauseated) The term psychosomatic disorder means something similar to somatisation but includes other[patient.info]

Workup

The diagnosis of conversion disorder is one of exclusion or the failure to discover any indication of organic disease. Despite the nonspecific nature of the symptoms and the number of possible differential diagnoses, recent studies have shown that less than 5% of patients are misdiagnosed [14].

Symptoms of conversion disorder suggest a neurologic disease, but no physical examination or diagnostic testing can find an explanation. It is therefore a diagnosis of exclusion. A complete physical exam must be accompanied by a comprehensive psychosocial history. [1].

A diagnosis of conversion disorder depends on the following criteria [2]:

  • One or more neurologic symptoms that affect voluntary motor or sensory function. 
  • Onset of symptoms is preceded by psychological stressors. 
  • Symptoms are not voluntary but unconscious
  • Symptoms cannot be explained by an underlying medical disorder, substance use, injury, or mental health diagnosis 
  • Symptoms result in decreased function and quality of life.

Clinical work-up should pay particular attention to a neurologic exam and mental status. The neurologic examination must distinguish between psychogenic and neurologic symptoms. The examination should also include observations when patient is not aware of being observed.

Mental status examination should include assessment of [1]:

  • Behavior
  • Appearance (Dress, eye contact, hygiene)
  • Attitude, mood, affect
  • Orientation to person, place, and time
  • Speech
  • Memory, attention, and concentration
  • Insight and judgment

Beyond a general physical examination to rule out systemic disease and complete neurological exam, other laboratory and imaging studies may be helpful in determining a physiologic cause of the symptoms such as:

  • Complete blood count
  • Erythrocyte sedimentation rate, antinuclear antibody, extractable nuclear antibody
  • Thyroid-stimulating hormone
  • HIV antibody, Lyme antibody, Anti-streptomycin antibody
  • Human chorionic gonadotropin
  • Magnetic resonance imaging of brain and cervical region
  • Electroencephalogram
  • Echocardiogram, Holter monitor
  • Urine and serum toxin screen for stimulant or illicit drug use
  • Drug levels (Anticonvulsants, digoxin)
  • Hypnosis or Amytal interview
  • Video-electroencephalography for non-epileptic seizures [4] [15]

Treatment

Once all possible neurological diagnoses have been excluded, the diagnosis of conversion disorder is made. Treatment depends on identification of the underlying psychological or emotional stressors. A therapeutic relationship between the patient and the healthcare community is essential in all cases. Where comorbid psychiatric diagnoses are involved these need to be treated adequately. Research suggests that a combination of antidepressants and psychotherapy may be beneficial [1].

Elimination of the stressors and the internal emotional conflict are potentially effective in removing the symptoms. Also, once the primary and secondary gains the patient receives from the symptoms are removed, the symptoms usually resolve.

Acceptance of the diagnosis is instrumental in the management of the disorder. How the patient is informed of the diagnosis is important and should be by the primary care provider who knows the patient and family well [14].

The early involvement of the patients’ family may help the discussion but as of now there is no research to establish this fact [7]. Family and friends can be instrumental in the resolution of the condition. Their primary role is to stop reinforcing the symptoms, while accepting the problem as real [14].

Even when symptoms resolve, patients with conversion disorder still require psychological or psychiatric treatment [13]. It should be remembered that the conversion symptoms are, just that, symptoms of a more serious emotional or psychological disorder.
Although psychotherapy is the recommended, patients with conversion disorder may not comply. The psychiatric diagnosis removes the possibility of a neurologic diagnosis that serves some purpose for the patient. Patients who do not accept the diagnosis will not seek mental health treatment that may influence patient outcomes [14].

Forms of psychotherapy that may be useful in the treatment of conversion disorder include [14]:

  • Individual psychotherapy to address predisposing, precipitating, and perpetuating factors
  • Cognitive behavioral therapy 
  • Group therapies 
  • Family therapy

There are no specific medications available for conversion disorder. Medications for associated mood, anxiety, and psychiatric disorders may be helpful. In patients with non-epileptic seizures, tapering and discontinuation of all antiepileptic drugs should be done upon diagnosis [4].

Regular follow-up with primary care provider, psychiatrist, counselor, and neurologist are necessary Prognosis and patient outcome is dependent on frequent and good communication between these providers of care. A coordinated plan of care may prevent unnecessary interventions, diagnostics, and treatments [1] [14].

Prognosis

Conversion disorder symptoms are usually self-limiting with no residual physical effects or disabilities. They do, however, result in decreased quality of life. Spontaneous resolution of symptoms occurs in approximately 75% of patients. Recurrence of symptoms occurs in approximately 25% of patients [1] [3].

Conversion disorder does often result in unnecessary diagnostic testing and therapeutic interventions in an attempt to determine a diagnosis for the patient's symptoms.

Misdiagnosis occurs occasionally, with approximately 25% of patients subsequently diagnosed with neurological disease. Multiple sclerosis, neurodegenerative diseases, structural myelopathy, and peripheral neuropathy are the most common.

The following are predictors of a good prognosis [1] [8]:

  • Acute onset of symptoms
  • Short duration of symptoms
  • Healthy functioning before onset
  • No coexisting psychopathology
  • An identifiable stressor
  • Male gender

Etiology

Conversion disorder was first identified in the 1880s by Freud and Breuer. They hypothesized that the physical symptoms of conversion disorder were hysterical in nature.

In the 19th century, Pierre Janet described hysteria as a dissociative disorder following psychologically trauma that results in somatoform symptoms [2] [9]. The theory is that the trauma is converted by the patient’s unconscious into physical symptoms [10] [11].

Sigmund Freud, later theorized that these symptoms were due to a psychological defense mechanism and coined the term conversion reaction [2].

Epidemiology

The incidence of conversion disorder varies significantly from one population group to another. Rates have been reported to be as high as 11 to 22 cases per 100,000 [3] [4].

Research shows conversion disorder is more common in rural, lower socioeconomic and education groups [4], as well as an increased in patients with a history of sexual or physical abuse is [7] [9].

The female-to-male ratio for conversion disorder is higher in females. In many studies the incidence is report as 2 to 5:1 female to make [4].

The onset of symptoms may occur at any age, but the peak onset appears to be from 20 to 40 years of age [2].

Sex distribution
Age distribution

Pathophysiology

Conversion disorder presents as a physical symptom or complaint to which no physical cause can be found and so is determined to be the result of psychological factors. Symptoms are thought to be due to an internal emotional conflict that the patient has repressed into the unconscious [10] [11].

Behavioral psychology’s attachment theory gives a developmental explanation for conversion disorder. It theorizes defense mechanisms, the ‘freeze response’ and ‘appeasement defense’, are to blame. Symptoms occur when the individual feels threatened. In this context the symptoms are self-protective [12]. This theory explains, in part, why conversion disorder occurs with more frequency in individuals who have a history of emotional or physical abuse [7] [9].

Patients with conversion disorder receive both primary and secondary gains from the symptomatology. The symptoms allow them to express suppressed emotional conflict unconsciously that they are unable admit openly. Secondary gains include avoidance of disagreeable situations, support from family and friends and attention from the medical community. Conversion symptoms are a learned behavior that are maladaptive but supported by the environment [10] [12].

Recent advances in neuroimaging may provide another hypothesis. Several studies have indicated a physical connection related to cerebral blood flow. Individuals with organic disease show an abnormally increase in blood flow to the primary motor cortex and thalamus and decreases to the cerebellum. In conversion disorder the opposite is seen with increased blood flow to the cerebellum and basal ganglia and decreases to the primary motor cortex [2] [8]. As yet, no determination of the meaning and effect of these findings are available.

Prevention

There is no clear way to prevent the incidence of conversion disorder as the cause of the disease remains unknown. This condition may be viewed as a cry for help from individuals unable to express deep emotional issues. Therefore, early detection and treatment of psychiatric and emotional problems may go a long way in preventing such conditions leading to conversion reactions.
The other way of preventing this disturbing and disabling disorder is to identify, prevent, and treat emotional and physical abuse.

Summary

Conversion disorder refers to the occurrence of one or more  sensory or motor neurological symptoms that have no identifiable organic cause, either neurologic or systemic [1] [2] [3]. Some common symptoms of conversion disorder include blindness, paralysis, speech anomalies, non-epileptic seizures, amnesia, dementia, swallowing difficulties, tics, hallucinations, and abnormal gait [4] [5].

Conversion disorder is thought to be a somatic disorder in that physical symptoms are an expression of psychological or emotional conflicts. The symptoms of conversion reactions are not under conscious control or intention [8] and have no identified precipitating or alleviating factors. Studies have shown a connection between conversion disorder and emotional or physical abuse [2] [7].

Conversion disorder can occur at any age past early childhood with a mean age of 30 years. There is a higher incidence in women than in men.

Since the neurobiological basis of conversion disorder is poorly understood, its management is difficult [8].

Patient Information

What is conversion disorder?

Conversion disorder refers to a condition in which one or more physical, usually neurological, symptoms are experiences where there is no organic or physical cause.  The presentation of conversion disorder varies widely and may include motor, sensory, speech, or seizure like symptoms. In the absence of identifiable pathology it is believed that conversion disorder has a psychological source. 

What are the symptoms?

The symptoms of conversion disorder vary widely from person to person. They may include:

What causes conversion disorder?

The cause of conversion disorder is not known. However it is felt to have a psychological or emotional basis.  It may appear as a result of an unrecognized physical or emotional trauma.

Who gets conversion disorder?

Conversion disorder can occur at any age, but is most common in individuals 20 to 40 years of age. It occurs in all ethnic groups.

It is more frequent in women than men, 2-5 to 1.

Its incidence is higher in people who have been the victims of physical, sexual, or emotional abuse.

How is it diagnosed ?

There is no specific diagnostic test for conversion disorder.  It is a diagnosis of exclusion. It is made when all possible physical or medical causes for the symptoms cannot be found.

How is conversion disorder treated ?

There is no specific treatment for conversion disorder. There are no medications or treatments that are curative.

Treatment involves psychiatric and psychological interventions such as individual, group, or family counseling, and possibly hypnosis.

What are the complications?

Conversion disorder interferes with the individual’s ability to interact successfully with others and with their environment. It may decrease the person’s functioning and quality of life. 

What can we do to prevent conversion disorder?

The incidence of conversion disorder may be prevented by early identification and treatment of emotional and psychological trauma and abuse.

References

Article

  1. Allin M, Streeruwitz A, Curtis V. Progress in understanding conversion disorder. Neuropsychiatr Dis Treat. 2005; 1(3):205-9. 
  2. Sar V, Islam S, Öztürk E. Childhood emotional abuse and dissociation in patients with conversion symptoms. Psychiatry and Clinical Neurosciences. 2009; 63: 670–677.
  3. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ. 2005;331(7523):989-93.
  4. O'Sullivan SS, Spillane JE, McMahon EM, et al. Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review. Epilepsy Behav. 2007;11(1):77-84.
  5. Blakemore RL, Hyland BI, Hammond-Tooke GD, Anson JG Distinct Modulation of Event-Related Potentials during Motor Preparation in Patients with Motor Conversion Disorder. PLoS ONE, 2013;8(4): e62539. 
  6. Hong J, Schonwald A, Stein MT. Barking vocalizations and shaking movements in a 13-year old girl. J Dev Behav Pediatr. 2008;29(2):135-7.
  7. Roelofs K, Keijsers GP, Hoogduin KA. Childhood abuse in patients with conversion disorder. Am J Psychiatry. 2002; 159(11):1908-13.
  8. Anette E. Schrag, AR. Mehta, KP. Bhatia, RJ. Brown, RS, Frackowiak J, Michael R.et al. The Functional Neuroimaging Correlates of Psychogenic versus Organic Dystonia. Brain. 2013;136(3):770-781.
  9. Singh SP, Lee AS. Conversion disorders in Nottingham: alive, but not kicking. J Psychosom Res. 1997;43(4):425-30.
  10. Aybek S, Kanaan RA, David AS. The neuropsychiatry of conversion disorder. Curr Opin Psychiatry. 2008;21(3):275-80. 
  11. Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, Sharpe M. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ. 2005; 331(7523):1756-1833.
  12. Kozlowska K. The developmental origins of conversion disorders. Clin Child Psychol Psychiatry. 2007;12(4):487-510. 
  13. Tsuruga K, Kobayashi T, Hirai N. Foreign accent syndrome in a case of dissociative (conversion) disorder. Seishin Shinkeigaku Zasshi. 2008;110(2):79-87.
  14. Boogaarts HD, Abdo WF, Bloem BR. "Recumbent" gait: relationship to the phenotype of "astasia-abasia?. Mov Disord. 2007;22(14):2121-2.
  15. LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013, 54(Suppl. 1):53–67.

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Last updated: 2018-06-22 04:04