Our current understanding of conversion disorder dates back to late 19th-century Paris. At that time, Sigmund Freud was studying neurology with Jean-Martin Charcot and became intrigued with the connection between the mind and body, particularly in women who displayed unusual neurologic symptoms. Many of these women were subsequently diagnosed with hysteria. Freud coined the term "conversion" based on his understanding that these individuals converted a psychological conflict or trauma into a physical symptom. Indeed, it was Freud's study of these patients that led him to develop his initial theories of psychoanalysis. Conversion disorder remains characterized by neurologic deficits that are not fully explained by a known neurologic or medical pathology. Psychological factors, such as conflicts or stress, are believed to either cause or exacerbate the symptoms. According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, conversion disorder is classified as a somatoform disorder [1]. Studies have reported that 5-15 percent of psychiatric consultations involve patients with conversion symptoms. The female-to-male ratio of those who suffer from this ailment has ranged from 2-to-1 up to 10-to-1. Although conversion disorder can occur at any age, it is most common in adolescents and young adults, and it is seen more frequently in individuals from rural areas, with less education, with lower IQ, and in military members exposed to combat [2]. The etiology of conversion disorder most likely involves psychological as well as biological and neurological factors. Classically, its symptoms have been explained as a result of unconscious conflict between a forbidden wish of a patient and his or her conscience. The conversion symptom symbolically represents a partial wish fulfillment without the individual's full awareness of the unacceptable desire. An example of this phenomenon is the person who experiences sudden paralysis of his arm due to an unconscious desire to strike his wife. The resulting condition both prevents him from acting on his wish and, in addition, may express underlying aggression by forcing his wife to compensate for his new disability. Biological factors that may characterize conversion disorder include impaired cerebral hemispheric communication, excessive cortical arousal that inhibits the individual's awareness of bodily sensations, and possibly subtle impairments on neuropsychological tests. The Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for conversion disorder require the presence of all of the following [3]:
The most common deficits of conversion disorder are paralysis, blindness, and mutism. Other common symptoms are anesthesias, paresthesias (particularly of the extremities), deafness, abnormal movements, gait disturbances, weakness, tremors, and seizures (so-called pseudoseizures). In all of the above, the presentation and physical exam are not consistent with a known neurological, anatomical, or physiological pathology. 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. The most important and difficult step in treating conversion disorder is making the correct diagnosis. Studies have found that 25-50 percent of patients diagnosed with conversion disorder are eventually discovered to have a medical condition that could have caused the symptoms. A thorough medical and neurologic workup is therefore essential for patients with suspected conversion disorder. Pathologic conditions that can look like conversion include brain tumors, multiple sclerosis, myasthenia gravis, basal ganglia disease, optic neuritis, Guillain-Barre, Creutzfeldt-Jakob, and AIDS. Somatization disorder may manifest with conversion characteristics, but patients with the former have a chronic course with physical symptoms in multiple other organ systems. Conversion disorder is often confused with both factitious disorder and malingering. In factitious disorder, individuals consciously create illness as a means to assume the sick role. Malingerers consciously fake symptoms or illness to achieve secondary gain (e.g., avoidance of work, jail, or military duty or obtaining compensation). Psychiatric disorders that are often present with conversion disorder include somatization and depressive, anxiety, and personality (particularly histrionic) disorders. It is not uncommon for patients with a conversion disorder to actually have some underlying neurologic pathology (such as a seizure disorder), in which case their conversion symptoms are elaborated. In most patients, conversion disorder tends to be self-limiting. As high as 90-100 percent of symptoms resolve in several days to a month. While many individuals never experience another episode, up to 25 percent have further episodes during times of stress. A better prognosis is associated with a sudden onset, a definite stressor, good premorbid functioning, lack of comorbid psychiatric disorders, and absence of litigation proceedings related to the illness. The longer conversion symptoms are present, the worse the prognosis. Confronting patients about the "psychological nature" of their symptoms can and usually does make them worse. Supportive psychotherapy, focused on coping with the underlying conflicts and stress, can help bring about a resolution to conversion disorder. Hypnosis and relaxation exercises can also be helpful. Administration of amobarbital or a benzodiazepine may help to obtain further history, particularly after an unremembered traumatic event. Other forms of psychotherapy, such as insight-oriented or short-term psychotherapies can also be of benefit.
References
Virtual Mentor. 2008;10(3):158-160. 10.1001/virtualmentor.2008.10.3.cprl1-0803.The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
Conversion disorder (also known as functional neurological system disorder) is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology. These problems are serious enough to negatively impact important life functions, such as academic performance, social relationships and family life. Children with conversion disorder are not faking or intentionally producing their physical or sensory problems. They are real, but the problems are not caused by underlying medical problems; rather, they are impairments in the normal functioning of the body. Conversion disorder is often, but not always, driven by poorly expressed distress, for which relief is provided by the existence of the symptoms.
Conversion disorder is still a poorly understood diagnosis in children. The name “conversion disorder” refers to the conversion of emotional stress to physical symptoms. But these same kinds of physical and sensory problems can occur with or without known psychosocial or traumatic stressors. Because of this, the broader term “functional neurological symptom disorder” is gaining acceptance for the condition. Diagnosis and treatment are essentially the same whether or not the problem has an identifiable emotional cause. Conversion disorder is more typical in girls than in boys. It is more common in older children and in adolescents, than in pre-pubertal children. Most children with conversion disorder do not have a history of behavioral problems, and have low conflict with authority figures. They are frequently recognized by family and friends as being upbeat and “even-keeled.” It is common for children with conversion disorder to deny any current life stressors. Children with conversion are most often high achievers at school, and often participate in performance athletics (e.g., figure skating, gymnastics), or play on advanced competitive sports teams.
Conversion disorder involves the loss of one or more bodily functions. Examples include:
To be considered conversion disorder, one or more of these problems must be present and be serious enough to interfere with a child’s ability to function successfully — at school, in social interactions, or at home.
All of the problems that are signs of conversion disorder can, of course, have medical and neurological causes and can be signs of significant medical conditions. Although it is through medical examination that conversion disorder is diagnosed, there are frequently behavioral clues that conversion disorder is the appropriate diagnosis. For example, symptoms often begin with maximal intensity, occur only in certain settings or with certain people, and cause more withdrawal from typical activities than would be seen in children with similar neurologic or medical disorders. Diagnosis generally begins with medical examination and testing by appropriate specialists, depending on the problems exhibited. These tests may include simple reflex checks, X-rays or other imaging, or an electroencephalogram (EEG) scan if the symptoms include seizures. This medical diagnosis must be done carefully, because the symptoms of conversion disorder can mimic those of other medical conditions. At the same time, a balance must be struck to avoid unwarranted invasive tests. In many cases, simple examination methods can be used to distinguish between problems with a neurological or medical basis from conversion symptoms. If the medical and neurological examinations are consistent with a diagnosis of conversion disorder, the diagnostic team expands to include a mental health provider with expertise in working with children and adolescents. The mental health provider may help the family identify thinking patterns, stressors or events that may be associated with the symptoms. However, with many families, there is no identified underlying stressor, or the stressor(s) take some time to identify. In these cases, mental health treatment focuses on the young person’s thinking patterns around his or her symptoms, as well as maximizing the child’s return to full functioning. Conversion disorder can sometimes occur in combination with other conditions, such as mood disorders, panic disorder, generalized anxiety disorder or post-traumatic stress disorder (PTSD). The psychological assessment will include a diagnosis of any other mental health issues that may need to be addressed in a treatment plan.
Children and families who receive a diagnosis of conversion disorder can initially be confused about or resistant to the idea that the problems have no medical or neurologic cause, and therefore are not treated medically. It is critical that the medical team make it clear that the problems are real, quite distressing, and not “in the child’s head.” It is, likewise, important that the team emphasize that this condition is highly treatable. An explanation of the relationship between mind and body, and how the two interact, is often a helpful starting point. For some children and their families, this explanation will be enough to begin the process of recovery. The hallmark of effective treatment for conversion disorder is emphasis on returning to age-appropriate functioning. This can begin with reinstitution of regular daily routines, and return to school and other activities. For young people with weakness, tremor or sensory loss, additional rehabilitative treatment may be needed. This may include:
For the majority of children, the symptoms of conversion disorder resolve within days to months. For most of these children, the symptoms will remit and never return. Early intervention, and return to regular activities is associated with the best outcomes.
In some cases, the symptoms of conversion disorder will disappear quickly and no follow-up care will be required. In other cases, longer-term physical, occupational or psychotherapy may be required. When conversion disorder is diagnosed with mental health conditions, regular psychotherapy follow-up is recommended.
Children’s Hospital of Philadelphia (CHOP) has a skilled team of child and adolescent mental health providers who work in collaboration with other medical specialists to diagnose and treat complex mind-body problems such as conversion disorder. Reviewed by |
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