Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Conversion Disorders

  • Author: Scott A Marshall, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Nov 09, 2015
 

Background

Conversion disorder (Functional Neurological Symptom Disorder) is categorized under the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) category of Somatic Symptom and Related Disorders.[1] It involves symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition. Yet, following a thorough evaluation, which includes a detailed neurologic examination and appropriate laboratory and radiographic diagnostic tests, no neurologic explanation exists for the symptoms, or the examination findings are inconsistent with the complaint. In other words, symptoms of an organic medical disorder or disturbance in normal neurologic functioning exist that are not referable to an organic medical or neurologic cause.[2]

Common examples of conversion symptoms include blindness, diplopia, paralysis, dystonia, psychogenic nonepileptic seizures (PNES), anesthesia, aphonia, amnesia, dementia, unresponsiveness, swallowing difficulties, motor tics, hallucinations, pseudocyesis and difficulty walking.

Reports of less common manifestations of conversion disorder abound in the literature and include camptocormia, clenched fist syndrome, recumbent gait, odd vocalizations, and pseudo foreign accent syndrome.[3, 4, 5, 6, 7]

Multiple symptoms suggest a somatization disorder. Conversion disorder is a type of somatoform disorder where physical symptoms or signs are present that cannot be explained by a medical condition. Very importantly, unlike factitious disorders and malingering, the symptoms of somatoform disorders are not intentional or under conscious control of the patient. See the image below.

French neurologist Jean Martin Charcot shows colle French neurologist Jean Martin Charcot shows colleagues a female patient with hysteria at La Salpêtrière, a Paris hospital.

Case study

A young woman’s family brings her to the hospital and she presents with a chief complaint of “spells.” It seems that over the past several weeks, the patient has suffered from attacks of bilateral arm jerking, followed by bilateral leg jerking after she lowers herself to the floor. Often, her head shakes violently side to side and her eyes are seen to "roll back in her head" followed by forced eye closure. These incidents follow episodes of emotional outbursts, and the patient is fortunately able to warn others that “I’m about to have a seizure!” After hearing this, her family grabs the patient and places her in a chair or on the ground until the spell is over, which sometimes can wax and wane for 20-30 minutes with varying intensity.

These spells are not accompanied by loss of bladder or bowel continence, but often the patient bites the tip of her tongue and kicks over tables or strikes family members during an episode. This most recent spell occurred while the patient was driving her car, in which she warned of an impending seizure and pulled the car to the shoulder just before losing consciousness; her spell was much more intense than she has had in the past.

She has no significant past medical history and takes no medications. She reports a past history of childhood sexual abuse from a paternal uncle several years ago. On exam, her vitals signs are normal and her neurologic evaluation is without significant findings. She is not orthostatic. Laboratory work-up, including urine toxin screen, is negative.

Next

Pathophysiology

Conversion symptoms suggest a physical disorder but are the result of psychological factors. According to the psychodynamic model, the symptoms are a consequence of emotional conflict, with the repression of conflict into the unconscious. In the late 1880s, Freud and Breuer suggested that hysterical symptoms resulted from the intrusion of "memories connected to psychical trauma" into the somatic innervation. This mind-to-body process was referred to as conversion. Others have introduced attachment theory as a means to understanding conversion disorder in terms of the freeze response and the appeasement defense behavior seen in animal subjects.[8]

The patient has been postulated to derive primary and secondary gain. With primary gain, the symptoms allow the patient to express the conflict that has been suppressed unconsciously. With secondary gain, symptoms allow the patient to avoid unpleasant situations or garner support from friends, family, and the medical system that would otherwise be unobtainable. According to sociocultural theories, the direct expression of emotions is impermissible and somatization takes its place. In behavioral models, conversion symptoms are viewed as a learned maladaptive behavior that is reinforced by the environment.

The idea that conversion disorder does not have an organic basis has become entrenched. However, some evidence supports the opposite notion. A review of imaging correlates in patients with motor and sensory conversion symptoms is referenced.[9, 10] Studies on the natural history of conversion disorder indicate that many patients subsequently develop or are found to have preexisting neurologic disease. In fact, conversion disorders may be more frequently observed in patients with a past history of a central nervous system injury. The simultaneous occurrence of organic brain disease with conversion symptoms is also observed, most notably in observation of high rates of organic seizure syndromes associated with psychogenic nonepileptic seizures (PNES). Familial studies have also shown that conversion symptoms in first-degree female relatives are up to 14 times greater than in the general population.

That the diagnosis of a conversion reaction of disorder represents a failed diagnosis of an organic syndrome, perhaps with psychogenic overlay that obscures exam and other findings is usually a valid concern. A recent meta-analysis including more than 1400 cases with follow-up over 5 years reported missed organic diagnosis rates of less than 5%.[11] This correlates with similar reports for the diagnosis of motor neuron disease or schizophrenia.[12] Past rates of misdiagnosis were reported as considerably higher.[11]

Previous
Next

Epidemiology

Frequency

United States

Stefansson et al report that the annual incidence of conversion reactions is 22 cases per 100,000 persons per year in Monroe County, New York. However, the reported rates vary widely.[13] In a study of 100 consecutive women following a normal full-term pregnancy, 33 were noted to have a past history of conversion symptoms. In a study of 100 randomly selected patients from a psychiatry clinic, 24 were noted to have unexplained neurologic symptoms. A report by Carson found that 30% of patients at a neurology clinic had "unexplained symptoms."[14]

Overall, conversion disorder is reported to be more common in rural populations, in individuals with lower socioeconomic status, lack of education, and low psychological sophistication.[15] The increased rate of conversion in patients with a past history of sexual or physical abuse is well described.[16, 17]

International

Stefansson et al report that the annual incidence is 11 cases per 100,000 persons per year in Iceland.[13]

Mortality/Morbidity

Individual conversion symptoms are generally self-limiting and do not lead to physical changes or disabilities. In the case of PNES, patients may have driving privileges removed by medical practitioners and may self-limit other activities due to concern over having a paroxysmal event. The symptoms related to the conversion disorder may lead to decreases in quality of life if they are perceived as egodystonic.

Morbidity is often an iatrogenic manifestation of unnecessary diagnostic or therapeutic interventions aimed at establishing an organic diagnosis for the patient's symptoms.

Patients with chronic conversion symptoms rarely may develop atrophy, frozen joints, and contractures from disuse.

Sex- and age-related demographics

Classically, the female-to-male ratio is 2-10:1.

Recent work with PNES reports that males make up approximately 40% of cases. This is a departure from past work, where females made up 80% of cases of PNES in some series.[18]

Overall, female-to-male ratio is variable, but the occurrence of conversion disorder is likely higher in females overall.

The typical onset is between the second and fourth decades.

The reported range is from children to individuals in their ninth decade of life.

Previous
 
 
Contributor Information and Disclosures
Author

Scott A Marshall, MD Major, Medical Corps, US Army; Assistant Professor of Neurology, Uniformed Services University of the Health Sciences; Staff Neurologist, Staff Intensivist, Brooke Army Medical Center

Scott A Marshall, MD is a member of the following medical societies: American Academy of Neurology, Wilderness Medical Society, Neurocritical Care Society

Disclosure: Nothing to disclose.

Coauthor(s)

Mark E Landau, MD Associate Professor of Neurology, Uniformed Services University of the Health Sciences; Consulting Staff, Assistant Chief, Section of Neurophysiology, Department of Neurology, Walter Reed Army Medical Center

Mark E Landau, MD is a member of the following medical societies: American Academy of Neurology, 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, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Bryan Schwieters, MD Consulting Physician, Schwieters Medical PLLC and VirtualPsych, LLC

Bryan Schwieters, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association

Disclosure: Received consulting fee from pfizer for speaking and teaching.

Alexis Llewellyn, PhD Licensed Psychologist and Owner, Katy Center for Psychology and Counseling Services

Alexis Llewellyn, PhD is a member of the following medical societies: American Psychological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

Acknowledgements

The opinions expressed in this work belong solely to those of the authors. They should not be interpreted as necessarily representative or endorsed by the Uniformed Services University, The United States Army, The Department of Defense, or any other agency of the federal government.

References
  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.

  2. Allin M, Streeruwitz A, Curtis V. Progress in understanding conversion disorder. Neuropsychiatr Dis Treat. 2005 Sep. 1(3):205-9. [Medline].

  3. Tsuruga K, Kobayashi T, Hirai N, et al. [Foreign accent syndrome in a case of dissociative (conversion) disorder]. Seishin Shinkeigaku Zasshi. 2008. 110(2):79-87. [Medline].

  4. Hong J, Schonwald A, Stein MT. Barking vocalizations and shaking movements in a 13-year old girl. J Dev Behav Pediatr. 2008 Apr. 29(2):135-7. [Medline].

  5. Boogaarts HD, Abdo WF, Bloem BR. "Recumbent" gait: relationship to the phenotype of "astasia-abasia"?. Mov Disord. 2007 Oct 31. 22(14):2121-2. [Medline].

  6. Skidmore F, Anderson K, Fram D, et al. Psychogenic camptocormia. Mov Disord. 2007 Oct 15. 22(13):1974-5. [Medline].

  7. Zeineh LL, Wilhelmi BJ, Seidenstricker L. The clenched fist syndrome revisited. Plast Reconstr Surg. 2008 Mar. 121(3):149e-150e. [Medline].

  8. Kozlowska K. The developmental origins of conversion disorders. Clin Child Psychol Psychiatry. 2007 Oct. 12(4):487-510. [Medline].

  9. Gurses N, Temucin CM, Lay Ergun E, et al. [Evoked potentials and regional cerebral blood flow changes in conversion disorder: a case report and review]. Turk Psikiyatri Derg. 2008 Spring. 19(1):101-7. [Medline].

  10. Blakemore RL, Hyland BI, Hammond-Tooke GD, Anson JG. Distinct modulation of event-related potentials during motor preparation in patients with motor conversion disorder. PLoS One. 2013. 8(4):e62539. [Medline]. [Full Text].

  11. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ. 2005 Oct 29. 331(7523):989. [Medline].

  12. Aybek S, Kanaan RA, David AS. The neuropsychiatry of conversion disorder. Curr Opin Psychiatry. 2008 May. 21(3):275-80. [Medline].

  13. Stefansson JG, Messina JA, Meyerowitz S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand. 1976 Feb. 53(2):119-38. [Medline].

  14. Carson AJ, Best S, Postma K, et al. The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study. J Neurol Neurosurg Psychiatry. 2003 Jul. 74(7):897-900. [Medline].

  15. Somatoform Disorders. Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O Gabbard, M.D. The American Psychiatric Publishing Textbook of Psychiatry. 5th. American Psychiatric Publishing, Inc.; 2008. 624-630. [Full Text].

  16. Singh SP, Lee AS. Conversion disorders in Nottingham: alive, but not kicking. J Psychosom Res. 1997 Oct. 43(4):425-30. [Medline].

  17. Roelofs K, Keijsers GP, Hoogduin KA, et al. Childhood abuse in patients with conversion disorder. Am J Psychiatry. 2002 Nov. 159(11):1908-13. [Medline].

  18. O'Sullivan SS, Spillane JE, McMahon EM, et al. Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review. Epilepsy Behav. 2007 Aug. 11(1):77-84. [Medline].

  19. Stone J, Smyth R, Carson A, et al. La belle indifférence in conversion symptoms and hysteria: systematic review. Br J Psychiatry. 2006 Mar. 188:204-9. [Medline].

  20. Slater E. Diagnosis of "Hysteria". Br Med J. 1965 May 29. 1(5447):1395-9. [Medline].

  21. Kuyk J, Leijten F, Meinardi H, et al. The diagnosis of psychogenic non-epileptic seizures: a review. Seizure. 1997 Aug. 6(4):243-53. [Medline].

  22. Betts T, Boden S. Diagnosis, management and prognosis of a group of 128 patients with non-epileptic attack disorder. Part I. Seizure. 1992 Mar. 1(1):19-26. [Medline].

  23. Brown LB, Nicholson TR, Aybek S, Kanaan RA, David AS. Neuropsychological function and memory suppression in conversion disorder. J Neuropsychol. 2013 Apr 15. [Medline].

  24. Gould R, Miller BL, Goldberg MA, et al. The validity of hysterical signs and symptoms. J Nerv Ment Dis. 1986 Oct. 174(10):593-7. [Medline].

  25. Ziv I, Djaldetti R, Zoldan Y, et al. Diagnosis of "non-organic" limb paresis by a novel objective motor assessment: the quantitative Hoover's test. J Neurol. 1998 Dec. 245(12):797-802. [Medline].

  26. Benbadis SR, Allen Hauser W. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure. 2000 Jun. 9(4):280-1. [Medline].

  27. Chung SS, Gerber P, Kirlin KA. Ictal eye closure is a reliable indicator for psychogenic nonepileptic seizures. Neurology. 2006 Jun 13. 66(11):1730-1. [Medline].

  28. Fekete R, Baizabal-Carvallo JF, Ha AD, Davidson A, Jankovic J. Convergence spasm in conversion disorders: prevalence in psychogenic and other movement disorders compared with controls. J Neurol Neurosurg Psychiatry. 2012 Feb. 83(2):202-4. [Medline].

  29. Marshall JC, Halligan PW, Fink GR. The functional anatomy of a hysterical paralysis. Cognition. 1997. 64:B1-B8.

  30. Hurwitz TA, Prichard JW. Conversion disorder and fMRI. Neurology. 2006 Dec 12. 67(11):1914-5. [Medline].

  31. Nichols LL, Zasler ND, Martelli M. Sodium amobarbital: historical perspectives and neurorehabilitation clinical caveats. NeuroRehabilitation. 2012. 31 (2):95-106. [Medline].

  32. Perry JC, Jacobs D. Overview: clinical applications of the Amytal interview in psychiatric emergency settings. Am J Psychiatry. 1982 May. 139(5):552-9. [Medline].

  33. Smith HE, Rynning RE, Okafor C, et al. Evaluation of neurologic deficit without apparent cause: the importance of a multidisciplinary approach. J Spinal Cord Med. 2007. 30(5):509-17. [Medline].

  34. Ness D. Physical therapy management for conversion disorder: case series. J Neurol Phys Ther. 2007 Mar. 31(1):30-9. [Medline].

  35. Shapiro AP, Teasell RW. Behavioural interventions in the rehabilitation of acute v. chronic nonorganic (conversion/factitious) motor disorders. Br J Psychiatry. 2004. 185:140-146.

  36. Masuda D, Hayaski Y. A case of dissociative (conversion) disorder treated effectively with haloperidol: an adolescent boy who stopped talking. Seishin Igaku (Clinical Psychiatry). 2003. 45:663-5.

  37. Cybulska EM. Globus hystericus--a somatic symptom of depression? The role of electroconvulsive therapy and antidepressants. Psychosom Med. 1997 Jan-Feb. 59(1):67-9. [Medline].

  38. Burneo JG, Martin R, Powell T, et al. Teddy bears: an observational finding in patients with non-epileptic events. Neurology. 2003 Sep 9. 61(5):714-5. [Medline].

  39. O'Sullivan SS, Spillane JE, McMahon EM, et al. Clinical characteristics and outcome of patients diagnosed with psychogenic nonepileptic seizures: a 5-year review. Epilepsy Behav. 2007 Aug. 11(1):77-84. [Medline].

  40. Pehlivanturk B, Unal F. Coversion disorder in children and adolescents: a 4-year follow up study. j Psychosom Res. 2002. 52:187-91.

  41. American Psychiatric Association. Somatoform disorders. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. Fourth Edition. Washington, DC: APA Press; 2000.

  42. Garofalo ML. The diagnosis and treatment of hysterical paralyses by the intravenous administration of pentothal sodium--case reports. 1942. Conn Med. 1992 Mar. 56(3):159-60. [Medline].

  43. Alao AO, Chung C. West Nile virus and conversion disorder. Psychosomatics. 2007 Mar-Apr. 48(2):176-7. [Medline].

  44. Benjamin James Sadock, M.D. and Virginia Alcott Sadock, M.D. Somatoform Disorders. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th Edition. Philadelphia, PA: Lippincott Williams & Wilkins; 2003. 647-651.

  45. Betts T, Boden S. Diagnosis, management and prognosis of a group of 128 patients with non-epileptic attack disorder. Part II. Previous childhood sexual abuse in the aetiology of these disorders. Seizure. 1992 Mar. 1(1):27-32. [Medline].

  46. Boffeli TJ, Guze SB. The simulation of neurologic disease. Psychiatr Clin North Am. 1992 Jun. 15(2):301-10. [Medline].

  47. Bourgeois JA, Chang CH, Hilty DM, et al. Clinical Manifestations and Management of Conversion Disorders. Curr Treat Options Neurol. 2002 Nov. 4(6):487-497. [Medline].

  48. Carter AB. The prognosis of certain hysterical symptoms. Br Med J. 1949 Jun 18. 1(4615):1076-9. [Medline].

  49. Cloninger CR, Martin RL, Guze SB, et al. A prospective follow-up and family study of somatization in men and women. Am J Psychiatry. 1986 Jul. 143(7):873-8. [Medline].

  50. Cohen RJ, Suter C. Hysterical seizures: suggestion as a provocative EEG test. Ann Neurol. 1982 Apr. 11(4):391-5. [Medline].

  51. de Lange FP, Roelofs K, Toni I. Motor imagery: a window into the mechanisms and alterations of the motor system. Cortex. 2008 May. 44(5):494-506. [Medline].

  52. Devinsky O, Thacker K. Nonepileptic seizures. Neurol Clin. 1995 May. 13(2):299-319. [Medline].

  53. Fahn S. Psychogenic movement disorders. Movement Disorders. Oxford, UK: Butterworth-Heinemann; 1994. Vol 3: 359-72.

  54. Gould R, Miller BL, Goldberg MA, et al. The validity of hysterical signs and symptoms. J Nerv Ment Dis. 1986 Oct. 174(10):593-7. [Medline].

  55. Han D, Connelly NR, Weintraub A, et al. Conversion locked-in syndrome after implantation of a spinal cord stimulator. Anesth Analg. 2007 Jan. 104(1):163-5. [Medline].

  56. Kuluva J, Hirsch S, Coffey B. PANDAS and paroxysms: a case of conversion disorder?. J Child Adolesc Psychopharmacol. 2008 Feb. 18(1):109-15. [Medline].

  57. Leis AA, Ross MA, Summers AK. Psychogenic seizures: ictal characteristics and diagnostic pitfalls. Neurology. 1992 Jan. 42(1):95-9. [Medline].

  58. Lesser RP. Psychogenic seizures. Neurology. 1996 Jun. 46(6):1499-507. [Medline].

  59. Ljungberg L. Hysteria: A clinical, prognostic and genetic study. Acta Psychiatr Scand Suppl. 1957. 112:1-162.

  60. Marchetti RL, Kurcgant D, Neto JG, et al. Psychiatric diagnoses of patients with psychogenic non-epileptic seizures. Seizure. 2008 Apr. 17(3):247-53. [Medline].

  61. Mari F, Di Bonaventura C, Vanacore N, et al. Video-EEG study of psychogenic nonepileptic seizures: differential characteristics in patients with and without epilepsy. Epilepsia. 2006. 47 Suppl 5:64-7. [Medline].

  62. Marjama J, Troster AI, Koller WC. Psychogenic movement disorders. Neurol Clin. 1995 May. 13(2):283-97. [Medline].

  63. Merskey H. Conversion symptoms revised. Semin Neurol. 1990 Sep. 10(3):221-8. [Medline].

  64. Ness D. Physical therapy management for conversion disorder: case series. J Neurol Phys Ther. 2007 Mar. 31(1):30-9. [Medline].

  65. Nisbet BC, Penfil S. Conversion disorder mimicking serotonin syndrome in an adolescent taking sertraline. Del Med J. 2008 Apr. 80(4):141-4. [Medline].

  66. Ruddy R, House A. Psychosocial interventions for conversion disorder. Cochrane Database Syst Rev. 2005 Oct 19. CD005331. [Medline].

  67. Sar V, Akyuz G, Kundakci T, et al. Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry. 2004 Dec. 161(12):2271-6. [Medline].

  68. Sar V, Kundakci T, Kiziltan E. Differentiating dissociative disorders from other diagnostic groups through somatoform dissociation in Turkey. J Trauma Dissociation. 2000. 1:67-80.

  69. Schrag A, Lang AE. Psychogenic movement disorders. Curr Opin Neurol. 2005 Aug. 18(4):399-404. [Medline].

  70. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology. 1990 May. 40(5):756-9. [Medline].

  71. Sirois FJ. Hysteria and technology: was Eliot Slater right?. Psychosomatics. 2008 Mar-Apr. 49(2):176-7. [Medline].

  72. Spence SA, Crimlisk HL, Cope H, et al. Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement. Lancet. 2000 Apr 8. 355(9211):1243-4. [Medline].

  73. Stevens H. Is it organic or is it functional. Is it hysteria or malingering?. Psychiatr Clin North Am. 1986 Jun. 9(2):241-54. [Medline].

  74. Vuilleumier P, Chicherio C, Assal F, et al. Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain. 2001 Jun. 124:1077-90. [Medline].

 
Previous
Next
 
French neurologist Jean Martin Charcot shows colleagues a female patient with hysteria at La Salpêtrière, a Paris hospital.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.