203 Conversion Disorder (300.11)

• A conversion disorder is a psychiatric disorder with a physical manifestation (Deaton, 1998).
• It is a specific form of somatization in which the patient presents with symptoms and signs that are confined to the voluntary central nervous system (Hurtwitz, 2004).
• The disorder’s basis is believed to be the substitution of a physical symptom for an emotional conflict that cannot be expressed openly (Deaton, 1998).

DSM-IV-TR criteria

A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflict or other stressors.

C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of function or warrants medical evaluation.

F. 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.

Barlow and Durand (2009) give an example of conversion disorder:

Eloise sat on a chair with her legs under her, refusing to put her feet on the floor. Her mother sat close by, ready to assist her if she needed to move or get up. Her mother had made the appointment and, with the help of a friend, had all but carried Eloise into the office. Eloise was a 20-year-old of borderline intelligence who was friendly and personable during the initial interview and who readily answered all questions with a big smile. She obviously enjoyed the social interaction.

Eloise’s difficulty walking developed over 5 years. Her right leg had given way and she began falling. Gradually, the condition worsened to the point that 6 months before her admission to the hospital Eloise could move around only by crawling on the floor.

Physical examinations revealed no physical problems. Eloise presented with a classic case of conversion disorder. Although she was not paralyzed, her specific symptoms included weakness in her legs and difficulty keeping her balance, with the result that she fell often. This particular type of conversion symptom is called astasia-abasia.

Eloise lived with her mother, who ran a gift shop in the front of her house in a small rural town. Eloise had been schooled through exceptional education programs until she was about 15; after this, no further programs were available. When Eloise began staying home, her walking began to deteriorate.

Associated features

• Some people with Conversion Disorder may display la belle indifference. This is a relative lack of worry about their condition or its implications. Other people may act in a dramatic or histrionic manner.
• These individuals, often being suggestible, may show symptoms that are modified or resolved by external cues. These symptoms are, however, not specific to this disorder and may also occur with a general medical condition.
• Symptoms may more commonly follow extreme psychosocial stress.
• Individuals being treated for Conversion Disorder may develop dependency issues and embrace an ailing role during the course of their treatment.
• Symptoms caused by Conversion Disorder usually conflict with established anatomical or physiological knowledge and explanations. Therefore, objective signs that indicate the presence of a traditional abnormality are frequently absent. They may, however, develop symptoms that resemble those observed in others or themselves. Individual symptoms generally do not lead to physical changes, but when they do, changes such as atrophy and contractures may occur.
• Laboratory analysis of the condition typically do not yield any findings either. The absence of any findings is a feature that may indicate that Conversion Disorder is the actual source of the problem(s).
• Dissociative Disorders, Major Depression, and Histrionic, Antisocial, Borderline, and Dependent Personality Disorders are mental disorders than can be associated with Conversion Disorder.

Child vs. adult presentation

• The symptoms that children with conversion disorder experience are frequently limited to seizure or gait problems. There is a wide range of symptoms that adults with Conversion Disorder may experience. These symptoms may include the loss of sensation, paralysis, blindness, seizures, or a mixed presentation.
• Conversion disorders are more common in adolescents than either children or adults (Deaton, 1998).

Gender and cultural differences in presentation

Conversion disorder is diagnosed more frequently in women than in men (Deaton, 1998). An exact ratio has not been established, but most studies indicate that the ratios range between 2:1 and 10:1. It is more common for women with Conversion Disorder to eventually develop Somatization Disorder, but there is a strong relation between Conversion Disorder and Antisocial Personality Disorder among men. It is common for men who experience Conversion Disorder to have suffered an industrial accident or to have been in the Military. It is much more common for women to experience symptoms on the left side of their body than in their right side.

There are various links between Conversion Disorder and cultural factors. People in rural settings, lower socioeconomic levels, and with relatively less knowledge of psychology and medicine are diagnosed with Conversion Disorder more frequently than other populations. There is a higher incidence of Conversions Disorder in developing regions than in developed regions, and reports from the developing regions decrease as further development occurs. The conversion symptoms displayed by patients may vary based on their culturally accepted means of demonstrating distress. One must be aware that the religious and healing rituals of certain cultures may include characteristics that could be confused with symptoms of Conversion Disorder.

Epidemiology

The prevalence of Conversion Disorder varies according to multiple reports, but the rates generally range from 11/100,000 to 500/100,000 in samples from the general population. About 3% of mental health clinic referrals are due to Conversion Disorder. Conversion Disorder is more likely to develop among older adolescents or young adults, women, and people from lower socioeconomic classes.

Onset is usually from late childhood to early adulthood, usually between the ages of 10 and 35, but onset as late as the ninth decade has been reported. When the disorder first develops in middle or old age, an occult neurological or other general medical condition is highly probable. The onset is usually acute, but the symptoms may also sometimes appear gradually. Individual symptoms are usually short in duration. Recurrence is common, and a single recurrence predicts future episodes. An acute onset, presence of clearly identifiable stress at the time of onset, a short interval between onset and treatment, and above-average intelligence are factors associated with a good prognosis. Symptoms of aphonia, blindness, and paralysis are also associated with a good prognosis, whereas tremors and seizures are not.

Etiology

The exact cause of Conversion Disorder has not been established by empirically supported data, but there are some theories about its development. Many contemporary theories claim that the development of Conversion Disorder is often sudden, and it is triggered by subconscious conflict, unresolved grief, sexual trauma, or other stressful situations. In essence, these theories state that people with Conversion Disorder convert their psychological distress into physical symptoms to avoid any further mental anguish. Disturbances in the central nervous system may increase the likelihood and/or severity of any somatic symptoms.

Other factors may influence the development of Conversion Disorder. There is some evidence that Conversion Disorder may be genetically transmitted, but there is not enough data to prove this conclusively. Socioeconomic factors are also known to influence the development of this disorder, but the exact manner in which they impact an individual has not been definitively identified.

Research shows that Conversion Disorder is triggered by a significant stressor such as, difficulty with peer relationships, family discord or marital problems, difficulties with academics or economic hardship within the family.

Studies have also shown that children whose family members have a chronic illness are more likely to model their symptoms. Also, between 10% and 60% of children with Conversion Disorder had previous illness.

Empirically supported treatments

Patients referred for the treatment of conversion disorder must first be medically cleared for any neurological condition (Hurtwitz, 2004).

There are no empirically supported treatments for Conversion Disorder, but there are a couple of methods that are believed to help people with this disorder. Some research has recommended an anxiolytic or antidepressant agent (Tocchio, 2009). The most common methods are behavioral or cognitive behavioral treatments. Treatment plans need to be individualized due to the varying symptoms of each person, but there are some general guidelines. It is important to discover any psychological stressors an individual may have that precipitate somatic symptoms to cope with them. It is vital to help individuals recognize these stressors and to help them learn more adaptive methods for dealing with them. Manipulation of the patient’s social environment may be necessary in order to reinforce the patient’s non-symptomatic behavior. Physiotherapy is also a technique used to treat Conversion disorder. This therapy involves maintaining and restoring maximum movement and ability throughout life.

CBTs have been shown to improve patient functioning and reduce the cost of care (Tocchio, 2009).

Outpatient treatment of patients with conversion symptoms can be attempted using some of the strategies used in the inpatient setting (Hurtwitz, 2004).

Patients with chronic and entrenched conversion symptoms usually require admission to an inpatient psychiatric unit that has experience with conversion disorders (Hurtwitz, 2004).

DSM-V recommended revisions www.dsm5.org

Major changes:

#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.

#2: De-emphasize medically unexplained symptoms.

#3: Modify criteria for conversion disorder.

• Patients with conversion disorder typically present with neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. These presentations may be acute or chronic. Typical symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms, dizziness, speech and swallowing difficulties. In addition, the diagnosis will usually be supported by confirmatory physical signs or diagnostic investigations consistent with the diagnosis (such as, Hoover’s sign). Psychological factors may be associated with the onset of symptoms, but are not essential for the diagnosis. If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering. When the symptom is limited to pain or to a disturbance in sexual functioning, it is typically coded elsewhere in the DSM (a different Somatic Symptom Disorder diagnosis or in the Sexual Disorders Section).

The work group is recommending this disorder be renamed from Conversion Disorder to Functional Neurological Symptoms.

Criteria A, B, and C must all be fulfilled to make the diagnosis:

• A. One or more symptoms are present that affect motor or sensory function or seizure-like episodes.
• B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience.
• C. Physical signs or diagnostic findings that provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.
• D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.