Conversion disorder 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.

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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.

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

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

Sensory loss or distortion often is inconsistent when tested on more than one occasion and is incompatible with peripheral nerve or root distribution. Discrete patches of anesthesia or hemisensory loss that stop in the midline may be present. Classic dermatomes in patients with numbness usually are not followed.



Visual symptoms

Visual symptoms include monocular diplopia, triplopia, field defects, tunnel vision, and bilateral blindness associated with intact pupillary reflexes. Optokinetic nystagmus may be observed in patients with apparent blindness when exposed to a rotating striped drum.


Gait disturbances


Astasia-abasia is a motor coordination disorder characterized by the inability to stand despite normal ability to move legs when lying down or sitting. Patients walk normally if they think they are not being observed. Occasionally, while being observed, patients actively attempt to fall. This contrasts with those patients with organic disease who attempt to support themselves.

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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. Cyanosis is rare unless patients deliberately hold their breath. Reflexes (eg, pupillary, corneal) are retained but may be difficult to test due to tightly closed lids. Tongue biting and incontinence are rare unless the patient has some degree of medical knowledge about the natural course of the disease. In contrast to true seizures, pseudoseizures occur in the presence of other people and not when the patient is alone or asleep.

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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:
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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:
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Electrolyte disturbances Hypoglycemia Hyperglycemia Renal failure Systemic infection Toxins 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.

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.

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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 falsepositive 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 sarcomainduced 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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American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. 1994. Binzer M, Andersen PM, Kullgren G: Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry 1997 Jul; 63(1): 838[Medline]. Binzer M, Kullgren G: Motor conversion disorder. A prospective 2- to 5year follow-up study. Psychosomatics 1998 Nov-Dec; 39(6): 51927[Medline]. Drake ME: Conversion hysteria and dominant hemisphere lesions. Psychosomatics 1993 Nov-Dec; 34(6): 524-30[Medline].

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