eMedicine Specialties > Psychiatry > Psychosomatic

Conversion Disorders: Differential Diagnoses & Workup

Author: Scott A Marshall, MD, Senior Fellow, Neurocritical Care, Johns Hopkins University School of Medicine, Division of Neurosciences Critical Care; Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Coauthor(s): Mark E Landau, MD, Neurology Program Director, National Capital Consortium, Associate Professor, Uniformed Services University of the Health Science, Neurophysiology Section, Department of Neurology, Walter Reed Army Medical Center; Craig G Carroll, DO, Staff Neurologist, Head of Clinical Neurophysiology Section, Naval Medical Center Portsmouth; Bryan Schwieters, MD, Consulting Physician, Schwieters Medical PLLC and St Joseph's Hospital
Contributor Information and Disclosures

Updated: Dec 22, 2008

Differential Diagnoses

Other Problems to Be Considered

The differential diagnosis of conversion disorders is highly dependent on the manner in which the patient presents. Organic etiologies must be excluded. Some have suggested that conversion disorder not be considered a diagnosis of exclusion,1 although a thorough medical and neurologic clinical evaluation and appropriate diagnostic testing is warranted prior to making the diagnosis of conversion. If, for example, a diagnosis of psychogenic hemiparesis is considered, organic etiologies such as tumor, stroke, multiple sclerosis, and others should be ruled out. As in working up any disease, the clinician must weigh the risks and benefits of diagnostic testing to the patient's overall condition.

Other problems to be considered include the following:

  • Epileptic seizures including frontal lobe epilepsy
  • Syncope - Cardiogenic, hypovolemia, orthostasis
  • Syncopal convulsion
  • Movement disorders - Tics, startle attacks, tremors, myoclonus
  • Sleep disorders - Narcolepsy, night terrors, restless legs syndrome, rapid eye movement sleep behavioral disorder
  • Other psychiatric disorders - Depressive disorders, anxiety disorders, panic disorder, posttraumatic stress disorder (PTSD), dissociative disorders, psychotic disorders, other somatic disorders, intermittent explosive disorder
  • Malingering
  • Medications - Toxicity (eg, tremors from high levels of valproic acid), akathisia (from neuroleptics and possibly antidepressants), EPS from neuroleptics, withdrawal from medications such as benzodiazepines, opiates, and occasionally with antidepressants such as SSRIs or SNRIs
  • Environmental exposures to chemicals or heavy metals
  • Drugs of abuse (inhalants, hallucinogens)

Workup

Laboratory Studies

  • Hemiparesis
    • MRI of brain with diffusion-weighted imaging
    • MRI of cervical region
  • Pseudoseizure (PNES)
    • MRI of brain
    • EEG
    • Prolonged video-EEG monitoring
    • Echocardiogram
    • Holter monitor
    • Tilt-table test
    • Prolactin level 30 minutes after the event: An elevation above baseline can occur with partial seizures, generalized seizures, or syncope, but not with pseudoseizures.
    • Provocative EEG with placebo induction is no longer routinely performed in many centers.
  • Psychogenic movement disorders
    • MRI of brain
    • Twenty-four hour urine studies for copper, serum ceruloplasmin, and slit lamp examination for evidence of Kayser-Fleisher rings to look for evidence of Wilson disease
    • Thyroid-stimulating hormone, thyroid peroxidase antibodies, thyroglobulin antibodies
    • CBC count with smear for acanthocytes
    • Erythrocyte sedimentation rate, antinuclear antibody, extractable nuclear antibody, anticardiolipin antibody, lupus anticoagulant
    • HIV antibody, Lyme antibody, anti-streptolysin O (ASO) antibody
    • Human chorionic gonadotropin
    • Urine and serum toxin screen for stimulant or illicit drug use
    • Drug levels (ie, anticonvulsants, digoxin) 

Procedures

  • Hypnosis or Amytal interview
    • To ensure diagnosis and to facilitate disclosure of underlying psychiatric issues during psychiatric interview or therapy
    • 8 mL intravenous sodium Amytal 2.5% given over 20 minutes has temporarily resolved cases of psychogenic motor weakness and may have a lasting effect in some cases.28,29 Other protocols for dosage are referenced.30
    • This procedure carries significant risk and should be carried out by experienced physicians. Sodium Amytal is a barbiturate and carries risk of respiratory depression. It is contraindicated in cases of upper respiratory infection or airway edema, hemodynamic instability, significant liver or kidney dysfunction, and porphyria. A CPR cart with medications and personnel trained in their use should be available in case of emergency.30 This is cited in the literature as a technique that may occasionally be used to help facilitate the gathering of data but is not routinely performed in many centers.
    • Hypnosis is used on occasion and may also facilitate the data gathering process. This technique may also help alleviate the patient's anxiety and aid in relaxation.
  • Brain PET scan has demonstrated evidence of left dorsolateral prefrontal cortex hypofunction.
  • SPECT scan has shown decrease in regional blood flow in the thalamus and basal ganglia contralateral to the deficit.
  • Advanced imaging is not diagnostic of conversion disorder, and routine use for this purpose is not currently standard of care.
  • See Causes for rCBF studies.8

More on Conversion Disorders

Overview: Conversion Disorders
Differential Diagnoses & Workup: Conversion Disorders
Treatment & Medication: Conversion Disorders
Follow-up: Conversion Disorders
Multimedia: Conversion Disorders
References
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Further Reading

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Keywords

hysteria, conversion reaction, voluntary motor deficit, sensory function deficit, malingering, conversion symptoms, psychogenic hemiparesis, psychogenic paralysis, pseudoseizure, pseudo-seizure, psychogenic seizure, psychogenic movement disorder, psychogenic tremor, PNES, psychogenic nonepileptic seizures

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Contributor Information and Disclosures

Author

Scott A Marshall, MD, Senior Fellow, Neurocritical Care, Johns Hopkins University School of Medicine, Division of Neurosciences Critical Care; Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
Scott A Marshall, MD is a member of the following medical societies: American Academy of Neurology, Neurocritical Care Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Landau, MD, Neurology Program Director, National Capital Consortium, Associate Professor, Uniformed Services University of the Health Science, Neurophysiology Section, Department of Neurology, Walter Reed Army Medical Center
Mark E Landau, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Craig G Carroll, DO, Staff Neurologist, Head of Clinical Neurophysiology Section, Naval Medical Center Portsmouth
Craig G Carroll, DO is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine
Disclosure: Nothing to disclose.

Bryan Schwieters, MD, Consulting Physician, Schwieters Medical PLLC and St Joseph's Hospital
Bryan Schwieters, MD is a member of the following medical societies: American Medical Association and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Barry I Liskow, MD, Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Residency Program, University of Kansas School of Medicine; Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center
Barry I Liskow, MD is a member of the following medical societies: American Academy of Clinical Psychiatrists, American Academy of Psychiatrists in Alcoholism and Addictions, American Medical Association, American Psychiatric Association, and Research Society on Alcoholism
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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