CONVERSION DISORDER

Travis Phifer, M.D.

The Case of Anna O.
 Somatoform Disorders

Conversion disorder
Hypochondriasis
Somatization disorder
Body dysmorphic disorder
Pain disorder
 Somatoform Disorders
Definition
…taking the form of soma (w/ implication of
nonsomatic)…”unexplained disorders”

• A broad group of illnesses with bodily signs and symptoms

as the predominant focus, influenced by the psyche
• Concept of mind/body interactions, with signals from the
brain (?mechanism) indicating a problem
• Not based on theoretical construct or laboratory findings-
no significant substantiating data, yet vigorous and sincere
complaints “not imaginary”
 Conversion Disorder
Definition

• An illness of symptoms or deficits affecting voluntary motor or

sensory functions, suggesting another medical condition, but judged
due to psychological factors because of preceding conflicts or other
stressors.
• Symptoms or deficits are not intentionally produced, not due to
substance, and not limited to pain or sexual symptomatology.
• Gain is primarily psychological, and not social or monetary or legal.
 Conversion Disorder
Definition

• A disturbance of bodily function not conforming

to current concepts of neurological anatomy and
physiology:
– Characterized by the presence of one or more neurological
symptoms, unexplained by a known neurological or medical
disorder;
– Typically occurring in a setting of stress, and producing
considerable dysfunction;
– Requiring for diagnosis the association of psychological factors,
present at the initiation or exacerbation of symptoms.
 Conversion Disorder
History

• A disorder stemming from early concepts of hysteria:

– Sigmund Freud introduced the term conversion (based on his work
with Anna O); and
– Hypothesized that the symptoms of conversion reflect unconscious
conflict.
 Conversion Disorder
Comparative Nosology

• DSM-IV-TR conversion d/o=dissociative d/o in ICD-10

• Comorbid dissociative d/o in approximately 30% of
inpatients with DSM-IV-TR conversion disorder
 Conversion Disorder
Epidemiology

• Some symptoms, but not severe enough to warrant

diagnosis in 1/3 of general population at some time
• Lifetime risk by some studies of 33% for either transient or
longer-term disorder
• 25-30% of admissions to VA hospitals
• Range in general population of 11-300/100,000
• DSM-IV-TR range of 1-500/100,000
 Conversion Disorder
Epidemiology
• Estimate of 20-25% admitted to a general medical service with
conversion symptoms at some time during life
– Engel GL. Conversion symptoms. In: MacBryde CM, ed. 5th ed. Signs and symptoms: applied
pathologic physiology and clinical interpretation. Philadelphia: JB Lippincott, 1970:650-68.
• 5-16% on several psychiatric consultation services referred for
assistance in diagnosis and management of conversion symptoms
– Lazare A. Hysteria. In: Hackett TP, Cassem NH eds. MGH handbook of general hospital
psychiatry. St Louis: CV Mosby, 1978:117-40.
• 24% in 500 psychiatric outpatients with at least one
conversion symptom
– Guze SB, Woodruff RA, Clayton PJ. Am J Psychiatry. 1971;128:643-6.
 Conversion Disorder
Epidemiology

• Ratio of women to men

– Range of 2/1 to 10/1 in adults
– Increased female predominance in children
• Symptoms in women more common on left side of body
• Women with conversion symptoms more likely to
subsequently develop somatization disorder
• Association in men between conversion disorder and
antisocial personality disorder
• Men with conversion disorder often involved in occupation
or military accidents
 Conversion Disorder
Epidemiology

• Onset at any age, but most common in late childhood to

early adulthood (rare before 10 years of age, or after 35,
but reported as late as the ninth decade of life)
• Probability of occult neurological or other medical
condition high with onset of symptoms in middle or
old age.
 Conversion Disorder
Epidemiology
• Common Prototypes
– Rural populations
– Developing nations and regions
– Persons with limited education and medical knowledge,
or decreased IQ
– Lower socioeconomic groups
– Military personnel exposed to combat
• Increased Frequency
– Relatives of probands with conversion disorder
– Monozygotic, but not dizygotic, twin pairs
 Conversion Disorder
Epidemiology
• Cultural norms are important considerations
– The form of conversion may reflect cultural ideas about
acceptable ways to express distress (e.g. falling, or an
alteration of consciousness)
– Behaviors resembling conversion or dissociative
symptoms are aspects of certain culturally sanctioned
religious and healing ceremonies
 Conversion Disorder
Comorbidity
• Common Axis I psychiatric conditions:
– Depressive disorders (increased suicide risk)
– Anxiety disorders
– Somatization disorders
– Conversion in schizophrenia reported but considered uncommon,
yet ¼ to ½ admissions to a psychiatric unit for conversion disorder
have significant mood disorder or schizophrenia
• Personality Disorders
– 5 to 21% histrionic
– 9 to 40% passive-aggressive/dependent
– Antisocial
• Medical and especially neurological disorders occur frequently, with
elaboration of symptoms stemming from original organic lesion
 Conversion Disorder
Etiology

• Multidimensional
– Psychoanalytic Factors
– Learning Theory
– Biological Factors
 Conversion Disorder
Etiology
• Psychoanalytic Factors
– Repression of unconscious intrapsychic conflict (instinctual
impulse, e.g. aggression/sexuality, and prohibitions of expression)
– Conversion of anxiety into a physical symptom-”the symptom
binds anxiety”
– Symptoms allow partial although disguised expression of the
forbidden wish or urge, such as to avoid conscious confrontation
with the unacceptable impulses
– The conversion disorder symptom has symbolic relation to the
unconscious conflict (e.g. vaginismus with sexual desire, syncope
with arousal, paralysis with anger)
– Symptoms communicate need for special consideration/treatment
– The individual may derive secondary gain, with symptoms serving
as a nonverbal means of controlling or manipulating others
 Conversion Disorder
Etiology

• Learning Theory
– Conversion disorder considered as piece of classically
conditioned learned behavior
– Symptoms of illness, learned in childhood, are called
forth as a means of coping with an otherwise
impossible situation.
 Conversion Disorder
Etiology
• Biological Factors
– Brain imaging
• Hypometabolism of dominant hemisphere
• Hypermetabolism of nondominant hemisphere
• ? Impaired hemispheric communication
– Corticofugal feedback
• ? Excessive cortical arousal setting off negative feedback loops
between the cortex and reticular formation w/ inhibition
– Neuropsychological tests
• Subtle cerebral impairments in verbal communication,
memory, vigilance, affective incongruity, and attention
– Increased incidence with head trauma/organicity
 Conversion Disorder
Diagnosis

• DSM-IV-TR limits to those symptoms that affect a

voluntary motor or sensory function (i.e. neurological
symptoms)
 Conversion Disorder
DSM-IV-TR Criteria
• One or more symptoms or deficits affecting voluntary motor or
sensory function that suggest a neurological or other general medical
condition.
• 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 conflicts or other stressors
• The symptom or deficit is not intentionally produced or feigned (as in
factitious disorder or malingering).
• 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
 Conversion Disorder
DSM-IV-TR Criteria
• 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.
– Specify type of symptom or deficit:
• with motor symptom or deficit
• with sensory symptom or deficit
• with seizures or convulsions
• with mixed presentation
 Conversion Disorder
Clinical Features

• Most common symptoms

– Paralysis
– Blindness
– Mutism
 Conversion Disorder
Clinical Features
• Sensory symptoms
– Anesthesia and paresthesia common, especially in extremities (although
all sensory modalities can be involved)
– Distribution of the neurological deficit inconsistent with either central or
peripheral neurological disease (e.g. stocking-and-glove anesthesia, and
hemianesthesia beginning precisely along the midline)
– Possible involvement of organs of special sense (deafness,
blindness, tunnel vision)
• Unilateral or bilateral
• Intact sensory pathways by neurological exam
(e.g. conversion disorder blindness: ability to walk around without
collision or self-injury, with pupils reactive to light, and normal
cortical evoked potentials.)
 Conversion Disorder
Clinical Features
• Motor symptoms
– Abnormal movements (gait disturbance, weakness/paralysis)
– Movements generally worsen with calling of attention
– Possible gross rhythmical tremors, chorea, tics, and jerks
– Astasia-abasia (wildly ataxic/staggering gait, gross irregular/jerky
truncal movements, thrashing/waving of arms-rare falls w/o injury)
– Paralysis/paresis involving one, two, or all four limbs
(w/o conformation to neural pathways)
– Reflexes remain normal
– No fasciculations/muscle atrophy (except chronic conversion)
– Normal electromyography
 Conversion Disorder
Clinical Features
• Seizure symptoms
– Pseudoseizures
• Differentiation from true seizure difficult by clinical
observation alone
• 1/3 of those with pseudoseizures have coexisting epileptic
disorder
• Tongue biting, urinary incontinance, and injuries after falling
can occur (although generally absent)
• Pupillary and gag reflexes retained
• No postseizure increase in prolactin concentration
 Conversion Disorder
Clinical Features

• Associated psychological symptoms

– Primary gain
– Secondary gain
– La belle indifference
– Identification
 Conversion Disorder
Clinical Features
• Associated psychological symptoms
– Primary gain
• Internal conflicts remain outside awareness
– Secondary gain
• Tangible advantages and benefits as a result of being sick
(excuses from obligations and difficult situations, support and
assistance otherwise not forthcoming, control of behavior of
others)
 Conversion Disorder
Clinical Features
• Associated psychological symptoms
– La belle indifference
• Inappropriate cavalier attitude toward serious symptoms
(lacking in some, but also in other seriously ill medical patients
with stoic attitude-inaccurate determinant of conversion
disorder)
– Identification
• Unconscious modeling of symptoms after someone considered
important to the patient
• With pathological grief reaction, bereaved persons commonly
have symptoms of the deceased
 Conversion Disorder
Clinical Features
• No specific standard laboratory tests
– Absence of tests supports diagnosis
• Experimental psychophysiology
– Unique sympathetic nervous system response as
measured by skin conductance upon anxiogenic
stimulus
– More rapid cortical evoked potential spikes in
contralateral sensory cortex upon physical stimuli
 Conversion Disorder
Differential Disorder

The most important conditions in the differential diagnosis

are neurological or other medical disorders and substance-
induced disorders.
 Conversion Disorder
Differential Diagnosis

• Concomitant or previous neurological disorder or a

systemic disease affecting the brain reported in 18% to
64% of cases of conversion disorder
• 25% to 50% of cases classified as conversion disorder
eventually receive diagnoses of neurological or
nonpsychiatric medical disorders
 Conversion Disorders
Differential Diagnosis
• 7-11 year follow up of 99 patients: 22 (30%) of 73 available subjects
had organic illness accounting for presenting symptoms initially
diagnosed as conversion (Slater ETO, Glithero E J. Psychosom Res, 1965;9:9-13).
• 2.5-10 year follow up of 24 patients discharged form the neuroscience
services of a teahing hospital with diagnosis of conversion:
5 (21%) of 24 with diagnosable neurological disease (Gatfield PD, Guze SB.
Dis Nerv Syst, 1962;23:623-31).
• 6-12 month follow up of 50 patients discharged from the neurology
service of a teaching hospital with conversion in differential diagnosis:
7 (14%) found with organic illness and 3 (6%) with hysterical
elaboration of organic pathology (Raskin M, Talbott JA, Meyerson AT. JAMA,
1966;197:530-4).
• 64 patientswith diagnosis of conversion by psychiatric consultation
service followed for an average of 3.3 years: 8 (13%) with organic
illness (Stefansson JG, Messina JA, Meyerowitz S. Acta Psychiatr Scand, 1976;53:119-38).
 Conversion Disorder
Differential Diagnosis

Symptoms probably the result of conversion disorder if

resolved by suggestion, hypnosis, or parenteral
amobarbital or lorazepam.
 Conversion Disorder
Differential Diagnosis
• Neurological/medical disorders
– Dementia and other degenerative disorders
– Brain tumors, subdural hematoma
– Basal ganglia disease, myasthenai gravis, multiple sclerosis
– Polymyositis, acquired myopathies
– Optic neuritis
– Partial vocal cord paralysis
– Acquired myopathies
– Guillain-Barre, Creutzfeldt-Jacob, periodic paralysis
– AIDS (early neurological manifestations)
– Systemic lupus erythematous
– Idiopathic and sarcoma-induced osteomalacia
– Acquired, nereditary, and drug-induced dsytonias
 Conversion Disorder
Differential Diagnosis

• Psychiatric disorders
– Schizophrenia
Hallucinations presenting with conversion disorder generally present w/o other
psychotic symptoms and often involve more than one sensory modality w/
vague or fantastic content.
– Depressive disorders
– Anxiety disorders
Consider high anxiety states with phobia and panic attack associated
with somatic complaints (e.g. difficulty swallowing)
– Dissociative disorders
Dual diagnosis possible
 Conversion Disorder
Differential Diagnosis
• Somatization disorder
– Includes possible sensorimotor symptoms, but chronic coarse
beginning early in life involving many other organ systems
• Hypochondriasis
– No actual loss or distortion of function
– Chronic somatic complaints, not limited to neurological symptoms,
with characteristic attitudes and beliefs (disease phobia)
• Body dysmorphic disorder
– Imagined or slight defect in appearance, with no voluntary motor
or sensory dysfunction
• Pain disorder-symptoms limited to pain (solely psychological)
• Sexual dysfunction-symptoms limited to sex
 Conversion Disorder
Differential Diagnosis

• Malingering and factitious disorder

– Symptoms under conscious, voluntary control
– History with malingering usually more inconsistent and
contradictory than with conversion disorder
– Fraudulent behavior clearly goal directed with
malingering
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Tunnel vision Visual fields

Profound monocular blindness Swinging flashlight sign

(Marcus Gunn)
Binocular visual fields
Severe bilateral blindness “Wiggle your fingers;
I’m just testing coordination.”
Sudden flash of bright light
“Look at your hand.”
“Touch your index fingers.”
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Aphonia Request a cough

Intractable sneezing Observe

 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Coma Examiner opens eyes
Ocular cephalic maneuver
Syncope Head-up tilt test
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Anesthesia Map dermatomes

Hemianesthesia Check midline

Astasia-abasia Walking, dancing

Paralysis, paresis Hand drop onto face

Hoover test
Check of motor strength
 Conversion Disorder
Course and Prognosis

• Initial symptoms resolve within a few days to < a month

in 90 to 100% (95% remit spontaneously, usually by 2
weeks)
• 75% have no further episodes, with 20-25% recurring
within a year during periods of stress
• 25 to 50% present later with neurological disorders or
nonpsychiatric medical conditions affecting the nervous
system
 Conversion Disorder
Course and Prognosis

• Predictors of good prognosis

– Sudden onset
– Easily identifiable stressor
– Good premorbid adjustment
– No comorbid psychiatric or medical disorders
– No ongoing litigation
– Short duration
– Short interval between onset and initiation of treatment
– Above average intelligence
– Paralysis, aphonia, blindness (tremor and seizures-poor prognosis)
 Conversion Disorder
Management/Treatment

• Acute cases
– Reassurance/appropriate rehabilitation
• Resolution usually spontaneous
– Psychotherapy
• A relative contraindication
 Conversion Disorder
Treatment
• Chronic cases
– Aggressive therapy of comorbid psychiatric illness
– Double bind approach to therapy
– Pharmacotherapy
• Anxiolytic or antidepressant medications ?
• Amobarbital interview?
– Psychotherapy?
 Conversion Disorder
Management/Treatment
• Psychotherapy
– Insight-oriented supportive or behavior therapy
• Relationship with a caring and confident therapist most
important feature of the therapy
• Confrontation re symptoms being imaginary detrimental
• Suggestion of focus on stress and coping sometimes helpful for
those resistant to idea of psychotherapy
– Psychodynamic approaches
• Exploring intrrapsychic conflicts, and the symbolism of
conversion symptoms ???
 Conversion Disorder
Summation/Questions