The Art of Handling

Conversion
Disorder in
Emergency Room
DR. DAMBA BESTARI SP.KJ
Mental duluan atau
fisik duluan
 Body and Mental Connection
Tubuh dan mental: dua aspek dari satu substansi
Mental: Menggerakkan tubuh menjadi tubuh yang hidup
Istilah psikogenik: Pro dan Kontra
Holistik
HPA Axis: Stres dapat memengaruhi sistem tubuh sampai ke tingkat molekuler

Andri, 2013. Psikosomatik: Apa dan Bagaimana?

Courtesy of
Dirty
Medicine
Conversion Disorder

• Functional Neurological Symptom Disorder (DSM V)

• Dapat terjadi pada berbagai usia, > remaja hingga dewasa muda
• Jenis kelamin perempuan: 70%-95%
• Populasi umum: 0.1% to 0.7%,
• Populasi klinis: 3.3% to 6.3% and 14% to 33%
 Conversion Disorder
• La belle indifference: klasik
• It is characterized by the inappropriate and paradoxical absence of distress
despite the presence of an unpleasant symptom. Patients often deny
emotional difficulty.
• Unfortunately, la belle indifférence, histrionic personality, and secondary gain
are clinical features that appear to have no diagnostic significance. They can
easily be absent in patients with conversion disorder; they can be easily be
present in patients with traditional neurologic disorder.
• 5 orang dengan hysterical conversion reactions mengalami cedera dan infark
pada cerebral hemisphere kiri
 Etiologi

• Stres kronis
• Konflik emosional
• Riwayat kekerasan traumatis
• Komorbiditas dengan gangguan psikiatri lain
• Gangguan Kepribadian Histerionik, Ambang
Kriteria Diagnosis
Sign and
Symptoms
Sign and Symptoms

1. 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.
2. 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.
Sign and Symptoms
3. Sensory symptoms
Sensory loss or distortion often is inconsistent when tested on more than one
occasion and is often 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.
4. 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.
Sign and Symptoms

5. 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.
6. Pseudoseizures
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.
Sign and Symptoms

7. 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 primarily occur in the presence
of other people and not when the patient is alone or asleep.
 Kejang Konversi vs Kejang Neurologis

Abbasi O.H, Aw T. 2017.

Psychogenic Non-Epileptic Seizures:
Clinical Issues for Psychiatrists
Tatalaksana
Farmakologi
• Anti anxietas bila perlu
Clobazam 10 mg p.o
Lorazepam 0.5-1 mg p.o
Injeksi Diazepam 2 mg i.m
 Tatalaksana

• Psikoterapi: Terapi Utama!

(CBT, Psikoterapi psikodinamika)
• Memperbaiki coping mechanism,
regulasi emosi, pola pikir
• Saling melengkapi dengan
psikofarmaka (keseimbangan)
Dont’s
1. Memberikan komentar bahwa semua gejala
hanya psikis, tidak nyata
2. Menyatakan tidak ada yang salah secara medis
3. Buru-buru menyarankan untuk selalu berpikir
positif (toxic positivity)
4. Melakukan pemeriksaan penunjang yang kurang
diperlukan secara berulang kali
Do’s
1. Bersikap tenang, empatik dan hangat
2. Berempati terhadap keluhan, tanpa terlalu berlebihan
3. Berikan pasien privacy
4. Sadari bila ada transferensi dari pasien
5. Jelaskan bagaimana pikiran dan tubuh saling memengaruhi
6. Berikan obat yang sesuai untuk meredakan keluhan (less is more)
7. Konsultasi dengan neurolog dan psikiater
8. Berikan psikoterapi suportif dan relaksasi
Menu Relaksasi

Mencari dukungan sosial (support system) orang2 suportif

Tulis jurnal/buku harian
Hobi: Menonton film, membaca buku, melukis
Lakukan relaksasi pernapasan/relaksasi otot progresif
Pertahankan pola makan sehat, tidur cukup dan olahraga.
Diagnosis Banding
• Gangguan Neurologis
• Factitious disorder
• Somatic symptom disorder
• Illness anxiety disorder
• Malingering
“The sorrow which has no
vent in tears may make
other organs weep”
(Henry Maudsley)
◦ TERIMA KASIH
Referensi
1. Conversion Disorder in Emergency Medicine Treatment & Management, Oct 26, 2017.
Medscape. Seth Powsner, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP
2. Andri, 2016. Diagnosis and treatment of psychosomatic Disorder
3. Ruffalo M. 2020. On the Psychoanalytic Treatment of Conversion Disorder. Pscyhiatric Times.
4. Abbasi O.H, Aw T. 2017. Psychogenic Non-Epileptic Seizures: Clinical Issues for
Psychiatrists
5. Jhaveri D, Tye S, 2020. Depression and the Brain. Queensland brain institute.
6. Peeling J; Muzio MR. 2021. Conversion Disorder. Available at
https://www.ncbi.nlm.nih.gov/books/NBK551567/