Conversion disorder From Wikipedia, the free encyclopediaJump to: navigation, search Conversion diso rder Classification and

external resources ICD-10 F44 ICD-9 300.11 DiseasesDB 1645 MedlinePlus 000954 eMedicine emerg/112 med/1150 MeSH D003291 Conversion disorder causes patients to suffer apparently neurological symptoms, such as numbness, blindness, paralysis, or fits, but without a neurological caus e. It is thought that these problems arise in response to difficulties in the pa tient's life, and conversion is considered a psychiatric disorder in the Diagnos tic and Statistical Manual of Mental Disorders fourth edition (DSM-IV).[1] Formerly known as "hysteria", the disorder has arguably been known for millennia , though it came to greatest prominence at the end of the 19th century, when the neurologists Jean-Martin Charcot and Sigmund Freud and psychiatrist Pierre Jane t focused their studies on the subject. Before Freud's studies on hysteria, peop le who suffered from physical disabilities that were not caused by any physical impairments, known as hysterical patients, were believed to be malingering, suff ering from weak nerves, or just suffering from meaningless disturbances. The ter m "conversion" has its origins in Freud's doctrine that anxiety is "converted" i nto physical symptoms.[2] Though previously thought to have vanished from the we st in the 20th century, some research has suggested it is as common as ever.[3] The DSM-IV classifies conversion disorder as a somatoform disorder while the ICD -10 classifies it as a dissociative disorder. Contents [hide] 1 Definition 2 History 3 Presentation 4 Mass psychogenic illness 5 Diagnosis 5.1 Exclusion of neurological disease 5.2 Exclusion of feigning 5.3 Establishing a psychological mechanism 6 Causes 7 Epidemiology 7.1 Frequency 7.2 Culture 7.3 Gender 7.4 Age 8 Treatment 9 Prognosis 10 See also 11 References [edit] DefinitionDSM-IV defines conversion disorder as follows: One or more symptoms or deficits are present that affect voluntary motor or sens ory function suggestive of a neurologic or other general medical condition. Psychological factors are judged, in the clinician's belief, to be associated wi th the symptom or deficit because conflicts or other stressors precede the initi ation 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 factitiou s disorder or malingering). The symptom or deficit, after appropriate investigation, cannot be explained ful ly by a general medical condition, the direct effects of a substance, or as a cu lturally sanctioned behavior or experience. The symptom or deficit causes clinically significant distress or impairment in s ocial, 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 oc cur exclusively during the course of somatization disorder, and is not better ac counted for by another mental disorder. The nature of the association between the psychological factors and the neurolog ical symptoms remains unclear. Earlier versions of the DSM-IV employed psychodyn amic concepts, but these have been incrementally removed from successive version s. The tenth revision of the World Health Organization's International Classificati on of Diseases uses the term "conversion" as an alternative descriptor for the d issociative disorders class of mental and behavioural disorders (i.e. the F44 cl ass), with the explicit suggestion that dissociative and conversion symptoms pro bably share common psychological mechanisms.[4] In ICD-10, the dissociative [con version] disorders class includes 10 disorders that, in addition to specific cri teria for each individual disorder, must each meet the following general criteri a: No evidence of a physical disorder that can explain the symptoms that characteri ze the disorder (but physical disorders may be present that give rise to other s ymptoms); Convincing associations in time between the symptoms of the disorder and stressf ul events, problems or needs.[4] [edit] HistoryIn the 19th century, physicians such as Silas Weir Mitchell in the US and Paul Briquet and Jean-Martin Charcot in France developed ideas about pat ients sharing unexplained neurological symptoms. Charcot specialised in treating patients who were suffering from a variety of unexplained physical symptoms inc luding paralysis, contractures (muscles which contract and cannot be relaxed) an d seizures. Some of these patients sporadically and compulsively adopted a bizar re posture (christened arc-de-cercle) in which they arched their body backwards until they were supported only by their head and their heels. The term "conversion disorder" originated with Freud. He viewed these apparently neurological symptoms as a result of the conversion of intrapsychic distress in to physical symptoms. This distress was thought to cause the brain to unconsciou sly disable or impair a bodily function as a side effect of the original repress ion, which served to relieve the patient's anxiety.[5] However, some have claime d that patients do remain distressed by their symptoms in the long term[6] It has also been suggested that at least some of the classic psychoanalytic case s of hysteria, such as "Anna O.",[7] may actually have suffered from organic ill ness. In fact, in Studies On Hysteria in which Breuer's Anna O. case was first p resented, Freud wrote this: "Others of the patient's symptoms were not of a hyst erical nature at all. This is true, for example, of the neck cramps, which I con sider a modified version of migraine and which as such are not to be classified as a neurosis but as an organic disorder. Hysterical symptoms, however, regularl y become attached to these." Freud believed that all hysterical symptoms ultimat ely have some organic components.[8] [edit] PresentationConversion disorder can present with motor or sensory symptom s including any of the following:

Motor symptoms or deficits: Impaired coordination or balance Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor c onversion disorders) Impairment or loss of speech (hysterical aphonia) Difficulty swallowing or a sensation of a lump in the throat Urinary retention Psychogenic non-epileptic seizures or convulsions Fixed dystonia unlike normal dystonia[clarification needed] Tremor, myoclonus or other movement disorders Gait problems (Astasia-abasia) Syncope (fainting) Sensory symptoms or deficits: Impaired vision (hysterical blindness), double vision Impaired hearing (deafness) Loss or disturbance of touch or pain sensation Conversion symptoms typically do not conform to known anatomical pathways and ph ysiological mechanisms, but instead follow the individual's conceptualization of a condition. Typically, the less medical knowledge a person has, the more impla usible are the presenting symptoms. Persons with more sophisticated medical know ledge tend to have more subtle symptoms and deficits that may closely simulate n eurological or other general medical conditions.[9] [edit] Mass psychogenic illnessMain article: Mass psychogenic illness The DSM-IV-TR does not have specific diagnosis for mass psychogenic illness but the text describing conversion disorder states that "In 'epidemic hysteria,' sha red symptoms develop in a circumscribed group of people following 'exposure' to a common precipitant." [edit] DiagnosisThe diagnosis of conversion disorder involves three elements: th e exclusion of neurological disease, the exclusion of feigning, and the determin ation of a psychological mechanism. Each of these has difficulties. [edit] Exclusion of neurological diseaseConversion disorder presents with sympto ms that typically resemble a neurological disorder such as stroke, multiple scle rosis, epilepsy or hypokalemic periodic paralysis. The neurologist must carefull y exclude neurological disease, through examination and appropriate investigatio ns.[10] However, it is not uncommon for patients with neurological disease to al so have conversion disorder.[11] In excluding neurological disease, the neurologist has traditionally relied part ly on the presence of positive signs of conversion disorder certain aspects of t he presentation that were thought to be rare in neurological disease, but common in conversion. The validity of many of these signs has been questioned, however , by a study showing that they also occurred in neurological disease.[12] One su ch symptom, for example, is La belle indiffrence, described in DSM-IV as "a relat ive lack of concern about the nature or implications of the symptoms". In a late r study no evidence was found that patients with "functional" symptoms are any m ore likely to exhibit this than patients with a confirmed organic disease.[13] Another feature thought to be important was that symptoms would tend to be more severe on the non-dominant (usually left) side; there were a variety of theories such as the relative involvement of cerebral hemispheres in emotional processin g, or more simply just that it was "easier" to live with a functional deficit on the non-dominant side. However, a literature review of 121 studies established that this was not true, with publication bias the most likely explanation for th is commonly held view.[14] Although agitation is often assumed to be a positive sign of conversion disorder, release of epinephrine is a well-demonstrated cause

of paralysis from hypokalemic periodic paralysis.[15] The process of exclusion is not perfect, so misdiagnoses will occur. In a highly influential[16] study from the 1960s, Eliot Slater demonstrated that misdiagnos es had occurred in one third of his 112 patients with conversion disorder.[17] L ater authors have argued that the paper was flawed, however,[6][18] and a meta-a nalysis has shown that misdiagnosis rates since that paper are around 4%, the sa me as for other neurological diseases.[19] [edit] Exclusion of feigningConversion disorder is unique in DSM-IV in explicitl y requiring the exclusion of deliberate feigning. Unfortunately, this is only li kely to be demonstrable where the patient confesses, or is "caught out" in a bro ader deception, such as a false identity.[20] One neuroimaging study suggested t hat feigning may be distinguished from conversion by the pattern of frontal lobe activation;[21] however this is a research, rather than a clinical technique. T rue rates of feigning in medicine remain unknown, though neurological presentati ons of feigning may be among the more common.[22] [edit] Establishing a psychological mechanismThe psychological mechanism can be the most difficult aspect of the conversion diagnosis. DSM-IV requires that the clinician believe preceding stressors or conflicts to be associated with the dev elopment of the disorder, though how this might come about is still the subject of debate. [edit] CausesThe original Freudian model[2] suggested that the emotional charge of painful experiences would be consciously repressed as a way of managing the p ain, but this emotional charge would be somehow "converted" into the neurologica l symptoms. Freud later argued that the repressed experiences were of a sexual n ature.[23] As Peter Halligan comments, conversion has 'the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms'[24] Janet, the other great theoretician of hysteria, argued that symptoms arose thro ugh the power of suggestion, acting on a personality vulnerable to dissociation. [25] In this hypothetical process, the subject's experience of their leg, for ex ample, is split-off from the rest of their consciousness, resulting in paralysis or numbness in that leg. Later authors have attempted to combine elements of th ese models, but none of them has a firm empirical basis.[26] Some support for the Freudian model comes from findings of high rates of childho od sexual abuse in conversion patients[27] and from a recent neuroimaging study showing abnormal emotion processing of a traumatic event linked to motor process ing of the affected limb, in a patient with conversion.[28] Support for the diss ociation model comes from studies showing heightened suggestibility in conversio n patients,[29] and in abnormalities in motor imagery.[30] There has been much recent interest in functional neuroimaging in conversion. As researchers identify the mechanisms which underlie conversion symptoms it is ho ped these will allow the development of a neuropsychological model. A number of such studies have been performed, including some which suggest that blood flow i n patients brains may be abnormal while they are unwell. These have all been too small to be confident of the generalisability of their findings, however, so no neuropsychological model has been clearly established. A 2007 review stated that conversion disorder and dissociative disorders are sta tistically associated, share features such as a history of abuse and high sugges tibility, and likely have common underlying causes. It recommended that DSM shou ld follow ICD-10 and reclassify conversion disorder from a somatoform disorder t o a dissociative disorder.[31] An evolutionary psychology explanation for conversion disorder is that the sympt

om may have been evolutionarily advantageous during warfare. A non-combatant wit h these symptoms signals non-verbally, possibly to someone speaking a different language, that she or he is not dangerous as a combatant and also may be carryin g some form of dangerous infectious disease. This can explain that conversion di sorder may develop following a threatening situation, that there may be a group effect with many people simultaneously developing similar symptoms (as in mass p sychogenic illness), and the gender difference in prevalence.[32] [edit] Epidemiology[edit] FrequencyInformation on the frequency of conversion di sorder in the West is limited, in part due to the complexities of the diagnostic process. In neurology clinics, the reported prevalence of unexplained symptoms among new patients is very high (between 30 and 60%)[33][34][35] However, diagno sis of conversion typically requires an additional psychiatric evaluation, and s ince few patients will see a psychiatrist[36] it is unclear what proportion of t he unexplained symptoms are actually due to conversion. Large scale psychiatric registers in the US and Iceland found incidence rates of 22 and 11 newly diagnos ed cases per 100,000 person-years, respectively,[37] [edit] CultureAlthough it is often thought that the frequency of conversion may be higher outside of the West, perhaps in relation to cultural and medical attit udes, evidence of this is limited.[3] A community survey of urban Turkey found a prevalence of 5.6%.[38] Many authors have found occurrence of conversion to be more frequent in rural, lower socio-economic groups, where technological investi gation of patients is limited and individuals may be less knowledgeable about me dical and psychological concepts.[37][39][40] [edit] GenderHistorically, the concept of 'hysteria' was originally understood t o be a condition exclusively affecting women, though the concept was eventually extended to men. In recent surveys of conversion disorder (formerly classified a s "hysterical neurosis, conversion type"),[33][38] females predominate, with bet ween 2 and 6 female patients for every male. [edit] AgeConversion disorder may present at any age but is rare in children you nger than 10 years or in the elderly. Studies suggest a peak onset in the mid-to -late 30s.[33][37][38] [edit] TreatmentTreatment may include the following:[41] 1.Explanation. This must be clear and coherent as attributing physical symptoms to a psychological cause is not accepted by many educated people in western cult ures. It must emphasize the genuineness of the condition, that it is common, pot entially reversible and does not mean that the sufferer is psychotic. Taking an etiologically neutral stance by describing the symptoms as functional may be hel pful but further studies are required. Ideally, the patient should be followed u p neurologically for a while to ensure that the diagnosis has been understood. 2.Physiotherapy where appropriate; 3.Occupational Therapy to maintain autonomy in activities of daily living;[42] 4.Treatment of comorbid depression or anxiety if present. There is little evidence-based treatment of conversion disorder.[43][full citati on needed] Other treatments such as cognitive behavioral therapy, hypnosis, EMDR , and psychodynamic psychotherapy eeg brain biofeedback need further trials. [edit] PrognosisThe DSM-IV-TR states that conversion symptoms will in most cases disappear within 2 weeks in those hospitalized. One-fifth to one-quarter will h ave a recurrence within a year with this also predicting future recurrences. Acu te onset, clearly identifiable stress at this time, and short time between onset and treatment are associated with a favorable prognosis. [edit] See alsoConversion syndrome Hysterical contagion

Mass hysteria [edit] References1.^ Diagnostic and Statistical Manual of Mental Disorders, Four th Edition, American Psychiatric Association 2.^ a b Josef Breuer & Sigmund Freud, "Studies in Hysteria", 1895 3.^ a b Akagi, H. & House, A.O., 2001, The epidemiology of hysterical conversion . In P. Halligan, C. Bass, J. Marshall (Eds.) Hysterical Conversion: clinical an d theoretical perspectives (pp. 7387). Oxford: Oxford University Press. 4.^ a b The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines. World Health Organization. pp. 1267. http ://www.who.int/entity/classifications/icd/en/bluebook.pdf. 5.^ Breuer and Freud, "Studies in Hysteria", 1895 6.^ a b Stone, et al., JR Soc Med 2005; 98:547548 7.^ Alison Orr-Andrewes, "The case of Anna O: A Neuropsychiatric perspective", J ournal of the Psychoanalytic Association 1987, vol 35 p.399. 8.^ ( Breuer and Freud, *Studies on Hysteria* Basic Books, Inc. 2000, pg.96). 9.^ Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Ameri can Psychiatric Association 10.^ Stone J, Carson A, Sharpe M., 2005, Functional symptoms in neurology: Asses sment, Journal of Neurology, Neurosurgery and Psychiatry (Neurology in Practice) ; 76 (Suppl 1): 212 11.^ Eames P, 1992, "Hysteria following brain injury", Journal of Neurology, Neu rosurgery, and Psychiatry, Vol 55, 10461053 12.^ Gould R, Miller B L, Goldberg M A, Benson D F, 1986, The validity of hyster ical signs and symptoms, The Journal of nervous and mental disease, vol. 174, no 10, pp. 593597 13.^ Stone J, Smyth R, Carson A, Warlow C, Sharpe M., "La belle indifference in conversion symptoms and hysteria: systematic review." Br J Psychiatry. 2006 Mar; 188 pp. 2049. 14.^ Stone J, Sharpe M, Carson A, Lewis SC, Thomas B, Goldbeck R, Warlow CP. "Ar e functional motor and sensory symptoms really more frequent on the left? A syst ematic review." J Neurol Neurosurg Psychiatry. 2002 Nov;73(5) pp. 57881. 15.^ "Segal MM, Jurkat-Rott K, Levitt J, Lehmann-Horn F, Hypokalemic periodic pa ralysis - an owner's manual" 16.^ Slater, E. "Diagnosis of Hysteria"Br Med J 1965 May; 1 pp. 139599. 17.^ Slater ET, Glithero E. "A follow-up of patients diagnosed as suffering from "hysteria" J Psychosom Res 1965 Sep;9(1) pp. 913. 18.^ Ron M, "The Prognosis of Hysteria" In P. Halligan, C. Bass, J. Marshall (Ed s.) Hysterical Conversion: clinical and theoretical perspectives (pp. 7387). Oxfo rd: Oxford University Press. 19.^ Stone, et al., BMJ 2005 20.^ Krahn L, Hongzhe L, O'Connor K. "Patients who strive to be ill: Factitious disorder with physical symptoms." American Journal of Psychiatry, 2003; 160(6), pp. 11638. 21.^ Spence SA, Crimlisk HL, Cope H, Ron MA, Grasby PM. "Discrete neurophsyiolog ical correlates in prefrontal cortex during hysterical and feigned disorder of m ovement." Lancet 2000 Apr 8; 355(9211), pp. 12434. 22.^ Eckhardt A, "Factitious disorders in the field of neurology and psychiatry. " 1994; 62(12), pp. 5662. 23.^ Freud S, "Dora: Fragment of an analysis of a case of hysteria.", 1905 24.^ 'New approaches to conversion hysteria, Peter W Halligan, Christopher Bass, Derick T Wade, BMJ 2000; 320:14881489, 3 June. 25.^ Janet, P. "The Major Symptoms of Hysteria", 1920, 2nd Edition 26.^ Brown, RJ. "Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model." Psychol Bull. 2004 Sep;130(5):793812. 27.^ Roelofs K, Keijsers GP, Hoogduin KA, Nring GW, Moene FC., "Childhood abuse i n patients with conversion disorder." Am J Psychiatry. 2002 Nov;159(11):190813. 28.^ Kanaan RA, Craig TK, Wessely SC, David AS. "Imaging repressed memories in m otor conversion disorder." Psychosom Med. 2007 FebMar;69(2):2025. 29.^ Roelofs K, Hoogduin KA, Keijsers GP, Nring GW, Moene FC, Sandijck P. "Hypnot ic susceptibility in patients with conversion disorder." J Abnorm Psychol. 2002

May;111(2):3905. 30.^ Roelofs K, van Galen GP, Keijsers GP, Hoogduin CA. "Motor initiation and ex ecution in patients with conversion paralysis." Acta Psychol (Amst). 2002 May;11 0(1):2134. 31.^ Brown, R. J.; Cardena, E.; Nijenhuis, E.; Sar, V.; Van Der Hart, O. (2007). "Should Conversion Disorder Be Reclassified as a Dissociative Disorder in DSM V ?". Psychosomatics 48 (5): 369378. doi:10.1176/appi.psy.48.5.369. PMID 17878494. edit 32.^ Bracha, H. (2006). "Human brain evolution and the "Neuroevolutionary Time-d epth Principle:" Implications for the Reclassification of fear-circuitry-related traits in DSM-V and for studying resilience to warzone-related posttraumatic st ress disorder". Progress in Neuro-Psychopharmacology and Biological Psychiatry 3 0 (5): 827853. doi:10.1016/j.pnpbp.2006.01.008. PMID 16563589. edit 33.^ a b c Carson AJ, Ringbauer B, Stone J, McKenzie L, Warlow C, Sharpe M. "Do medically unexplained symptoms matter? A prospective cohort study of 300 new ref errals to neurology outpatient clinics." J Neurol Neurosurg Psychiatry. 2000 Feb ;68(2):20710. 34.^ Nimnuan C, Hotopf M, Wessely S. "Medically unexplained symptoms: an epidemi ological study in seven specialities." J Psychosom Res. 2001 Jul;51(1):3617. 35.^ Snijders TJ, de Leeuw FE, Klumpers UM, Kappelle LJ, van Gijn J. "Prevalence and predictors of unexplained neurological symptoms in an academic neurology ou tpatient clinican observational study." J Neurol. 2004 Jan;251(1):6671. 36.^ Crimlisk HL, Bhatia KP, Cope H, David AS, Marsden D, Ron MA. "Patterns of r eferral in patients with medically unexplained motor symptoms." J Psychosom Res. 2000 Sep;49(3):2179. 37.^ a b c Stefnsson JG, Messina JA, Meyerowitz S. "Hysterical neurosis, conversi on type: clinical and epidemiological considerations." Acta Psychiatrica Scandin avica 1976 Feb;53(2):11938. 38.^ a b c Deveci A, Taskin O, Dinc G, Yilmaz H, Demet MM, Erbay-Dundar P, Kaya E, Ozmen E. "Prevalence of pseudoneurologic conversion disorder in an urban comm unity in Manisa, Turkey." Soc Psychiatry Psychiatr Epidemiol. 2007 Nov;42(11):85 764. 39.^ Tomasson K, Kent D, Coryell W. "Somatization and conversion disorders: como rbidity and demographics at presentation." Acta Psychiatrica Scandinavica 1991 S ep;84(3):28893. 40.^ Kuloglu M, Atmaca M, Tezcan E, Gecici O, Bulut S. "Sociodemographic and cli nical characteristics of patients with conversion disorder in Eastern Turkey." S oc Psychiatry Psychiatr Epidemiol. 2003 Feb;38(2):8893. 41.^ Stone J, Carson A, Sharpe M. "Functional symptoms in neurology: management. " J Neurol Neurosurg Psychiatry. 2005 Mar;76 Suppl 1:i1321. 42.^ http://www.doctorsofusc.com/condition/document/96743 43.^ Ruddy R, House A. Psychosocial interventions for conversion disorder. Cochr ane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005331. doi:10.100 2/14651858.CD005331.pub2 [show]v t eMental and behavioral disorders (F 290319) [show] Neurological/symptomatic Dementia Mild cognitive impairment Alzheimer's disease Multi-infarct dementia Pick' s disease CreutzfeldtJakob disease Huntington's disease Parkinson's disease AIDS deme ntia complex Frontotemporal dementia Sundowning Wandering Autism spectrum Autism Asperger syndrome Savant syndrome PDD-NOS High-functioning au tism Other Delirium Post-concussion syndrome Organic brain syndrome

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