Conversion disorder

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Background: Conversion disorder is included as a somatoform disorder

under the general classification of hysterias in the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric Association, Fourth
Edition (DSM-IV). Although defined as a condition that presents as an
alteration or loss of a physical function suggestive of a physical disorder,
conversion disorder is more precisely understood as the expression of an
underlying psychological conflict or need.

The presence of the psychological factor usually is not apparent at onset but
becomes evident in the history when a cause-effect relationship between an
environmental event or stressor and the onset of the symptom is discovered.
The symptoms are not intentionally produced but are the result of
unintentional motives. This condition is not considered under voluntary control
and, after appropriate medical evaluation, cannot be explained by any
physical disorder or known pathological mechanism.

Clinical descriptions of conversion disorder date to almost 4000 years ago;

the Egyptians attributed symptoms to a "wandering uterus." In the 19th
century, Paul Briquet described the disorder as a dysfunction of the CNS.
Freud first used the term conversion to refer to the substitution of a somatic
symptom for a repressed idea.

Pathophysiology: The nature and character of presenting symptoms can

range the entire field of clinical neurology. A conversion reaction can be
entertained in the differential diagnosis of any neurological syndrome.
Reactions usually are characterized by symptoms that suggest lesions in the
motor or sensory pathways of the voluntary nervous system. Most commonly
reported symptoms are weakness, paralysis, sensory disturbances,
pseudoseizures, and involuntary movements such as tremors. Symptoms
more often affect the left side of the body. This loss or distortion of neurologic
function cannot adequately be accounted for by organic disease. Involvement
of the corticofugal inhibitory system has been suggested. Symptoms
specifically excluded are those limited to pain or sexual functioning or those
due to somatization disorder or schizophrenia.

Diagnostic criteria for conversion disorder as defined in the DSM-IV are as

follows:

• One or more symptoms or deficits are present that affect voluntary

motor or sensory function that suggest a neurologic or other general
medical condition.
• Psychologic factors are judged to be associated with the symptom or
deficit because conflicts or other stressors precede the initiation or
exacerbation of the symptom or deficit.
 • 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.

According to psychodynamic theory, conversion symptoms seem to be

maintained by operant conditioning. The person derives "primary gain" by
keeping an internal conflict or need out of awareness. The symptom has a
symbolic value that is a representation and partial solution of a deep-seated
psychological conflict.
According to learning theory, conversion disorder symptoms are a learned
"maladaptive response to stress." Patients achieve "secondary gain" by
avoiding activities that are particularly offensive to them, thereby gaining
support from family and friends, which otherwise may not be offered.
Frequency:
• 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.
• 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.

Mortality/Morbidity:
• Studies report that 64% of patients with conversion disorder show
evidence of an organic brain disorder, compared with 5% of control
subjects.

• 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.

Sex: 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.
Age:
• 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.

Clinical
History: Degree of impairment usually is marked and interferes with daily life
activities. Prolonged loss of function may produce organic complications such
as disuse atrophy or contractures.

• Weakness, paralysis, sensory disturbances, aphonia, deafness,

blindness, pseudoseizures, and involuntary movements (eg, tremors)
are the most frequent complaints. Symptoms often enable patients to
avoid an unpleasant situation at home or work, attract attention, or gain
support from others. This may become evident through careful
questioning.

• The symptom must not be under voluntary control. Determining the

symptom may be difficult, since it usually cannot be identified by
observation. Features suggestive of voluntary control consist of
variability, inconsistency, obvious and immediate benefit, as well as a
personality that may suggest dishonesty and opportunism. Symptoms,
if voluntary, tend to be self-limited and of brief duration.

• La belle indifférence 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 indifférence, 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.

Physical: Absence of a physical disorder is an important diagnostic feature.

Individuals with conversion disorder often have physical signs but lack
objective neurological signs to substantiate their symptoms.
• Weakness

o Weakness usually involves whole movements rather than

muscle groups. Weakness affects the extremities more often
than ocular, facial, or cervical movements.

o With the use of various clinical techniques, weakness of one

limb can be demonstrated to cause contraction of opposing
muscle groups. Discontinuous resistance during testing of power
or give-way weakness may exist. Muscle wasting is absent, and
reflexes are normal.

• Sensory symptoms

o Sensory loss or distortion often is inconsistent when tested on

more than one occasion and is incompatible with peripheral
nerve or root distribution.

o Discrete patches of anesthesia or hemisensory loss that stop in

the midline may be present.

o Classic dermatomes in patients with numbness usually are not

followed.

• Visual symptoms

o Visual symptoms include monocular diplopia, triplopia, field

defects, tunnel vision, and bilateral blindness associated with
intact pupillary reflexes.

o Optokinetic nystagmus may be observed in patients with

apparent blindness when exposed to a rotating striped drum.

• Gait disturbances
 o Astasia-abasia is a motor coordination disorder characterized by
the inability to stand despite normal ability to move legs when
lying down or sitting.

o Patients walk normally if they think they are not being observed.

o Occasionally, while being observed, patients actively attempt to

fall. This contrasts with those patients with organic disease who
attempt to support themselves.

• Pseudoseizures

o During an attack, marked involvement of the truncal muscles

with opisthotonos and lateral rolling of the head or body is
present. All 4 limbs may exhibit random thrashing movements,
which may increase in intensity if restraint is applied.

o Cyanosis is rare unless patients deliberately hold their breath.

o Reflexes (eg, pupillary, corneal) are retained but may be difficult

to test due to tightly closed lids.

o Tongue biting and incontinence are rare unless the patient has
some degree of medical knowledge about the natural course of
the disease.

o In contrast to true seizures, pseudoseizures occur in the

presence of other people and not when the patient is alone or
asleep.

Causes:
• By definition, symptoms in a conversion reaction are caused by
previous severe stress, emotional conflict, or an associated psychiatric
disorder.

• Many studies confirm high incidence of depression in patients with

conversion disorder. As many as half of these patients have personality
disorders or display hysterical traits.

• In children, conversion disorder often is observed following physical or

sexual abuse.

• Children who have family members with a history of conversion

reactions are more likely to suffer from conversion disorder. In addition,
if family members are seriously ill or in chronic pain, children are more
likely to be affected.

Deferential Diagnosis
Acute Compressive Optic Neuropathy]

Adrenal Insufficiency and Adrenal Crisis

Amyotrophic Lateral Sclerosis
Bell Palsy
Benign Positional Vertigo
Brain Abscess
CBRNE - Botulism
Cauda Equina Syndrome
Central Vertigo
Cysticercosis
Delirium, Dementia, and Amnesia
Depression and Suicide
Encephalitis
Epidural Hematoma
Epidural and Subdural Infections
Guillain-Barré Syndrome
Herpes Simplex
Herpes Simplex Encephalitis
Huntington Chorea
Lambert-Eaton Myasthenic Syndrome
Lumbar (Intervertebral) Disk Disorders
Meniere Disease
Multiple Sclerosis
Myasthenia Gravis
Neoplasms, Spinal Cord
Neuroleptic Malignant Syndrome
Panic Disorders
Pediatrics, Child Abuse
Rabies
Spinal Cord Infections
Syphilis
Tick-Borne Diseases, Lyme
Toxicity, Ciguatera
Toxicity, Medication-Induced Dystonic Reactions
Toxicity, Mercury
Toxicity, Neuroleptic Agents
[Toxicity, Selective Serotonin Reuptake Inhibitor]

Transient Ischemic Attack

Vestibular Neuronitis
Withdrawal Syndromes

Other Problems to be Considered:

Cerebellopontine angle tumors

Vertebrobasilar insufficiency
Creutzfeldt-Jakob disease
Lab Studies:

• Carefully consider the possibility of an organic etiology.

• Some authors have suggested that unnecessary, painful, or invasive

testing can result in reinforcement and fixation of symptoms and should
be avoided when possible.

• Consider laboratory testing to exclude the following clinical entities:

o Electrolyte disturbances

o Hypoglycemia
o Hyperglycemia

o Renal failure

o Systemic infection

o Toxins

o Other drugs

Imaging Studies:
• A chest x-ray (CXR) may be considered to diagnose an occult
neoplasm.

• CT scan or MRI may be performed to exclude a space-occupying

lesion in the brain or spinal cord.

Other Tests:
• An electroencephalograph may help distinguish pseudoseizures from a
true seizure disorder.

Procedures:
• Spinal fluid may be diagnostic in ruling out infectious or other causes of
neurologic symptoms.

Treatment
Prehospital Care: Treat patients as if their symptoms have an organic origin.
Prehospital personnel most often cannot distinguish a conversion reaction
from an organic illness.

Emergency Department Care: Emergency physicians must be aware that

the diagnosis of conversion disorder does not exclude the presence of
underlying disease, and diagnosis should not be made solely on the basis of
negative workup results. Approach each patient as if their symptoms had an
organic basis, and treat them accordingly.

Consultations: Consultation is often necessary and should be considered

during ED discharge planning for any patients without previous histories of
conversion reaction.

• Consultation may be a cost-effective method to eliminate unnecessary

hospitalization by streamlining these patients to appropriate outpatient
psychiatric follow-up.

• Neurologic consultation may help if the neurological examination is

equivocal.

• Psychiatric consultation may be necessary if an organic cause is

virtually excluded. Intense questioning may elicit the underlying
stressor.

• Another treatment technique is suggestive therapy, which consists of

faradic stimulation that the symptom spontaneously remits.

• Other suggestive therapies for symptom removal include hypnosis and

amobarbital interviews.
• Using a behaviorally oriented treatment strategy, the goals are to
unlearn maladaptive responses and to learn more appropriate
responses. Attempt to eliminate the patient's belief that the extremity is
paralyzed by telling the patient (1) that all tests indicate the muscles
and nerves are functioning normally, (2) the brain is communicating
with the nerves and muscles, and (3) this apparent lost ability is
recoverable. Confronting the patient with the fact that the symptoms
are not organic is counterproductive.

Further Outpatient Care:

• Any patient diagnosed with a conversion reaction in the ED requires

psychiatric follow-up.

• Many patients have spontaneous remission after outpatient

psychotherapy or suggestive therapy.

Transfer:
• All transfers must comply with Consolidated Omnibus Budget
Reconciliation Act (COBRA) regulations.

Complications:
• Errors in diagnosis of conversion disorder are not uncommon. The
false-positive diagnosis rate has been reported to be as much as 25%
in earlier studies. With newer diagnostic testing, instances of false-
positive diagnoses of conversion disorder in which a neurological
disease is later identified are extremely rare.
 • Recent studies have found a variety of organic diseases in patients
who were initially diagnosed with conversion disorder. In one case
report, a woman was seen with leg weakness and back pain who was
subsequently diagnosed with sporadic Creutzfeldt-Jakob disease.
Other patients with underlying psychiatric illnesses were found to have
disk herniations, epidural abscesses, or cerebral hemorrhages. In
another case series, 5 patients were identified as having sarcoma-
induced osteomalacia, cerebellar medulloblastoma, Huntington chorea,
transverse myelitis, and lower extremity dystonia. Although these case
reports were rare, the initial diagnosis of conversion disorder without a
complete neurologic examination, appropriate imaging, and other
diagnostic testing should be discouraged.

Prognosis:
• Prognostic studies differ in outcome, with recovery rates ranging from
15-74%. Factors associated with favorable outcomes are male gender,
acute onset of symptoms, precipitation by a stressful event, good
premorbid health, and an absence of organic or psychiatric disorder.

• Many patients with conversion reactions have spontaneous remission

or demonstrate marked or complete recovery after brief psychotherapy.

Medical/Legal Pitfalls:

• Underlying organic disease may be present in patients with conversion

disorder. Errors in diagnosis may be as much as 25%, especially with
the limited time and testing available in the ED. If uncertain as to the
etiology of the patient's symptoms or uncomfortable with a complicated
neurologic presentation, seek appropriate neurologic and psychiatric
consultation.

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