Conversion Disorders Treatment & Management

  • Author: Scott A Marshall, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Sep 16, 2009
 

Medical Care

Current understanding of the phenomenon of conversion disorder implicates some role of the unconscious in the pathophysiology of this condition.[10, 28] It is therefore less likely to respond to treatment when the manifestations of the conversion are confronted directly as a unitary method of therapy. Many patients who experience a conversion disorder are unable to understand this inner conflict, which is perhaps occurring on an unconscious level. They may achieve resolution of the conflict, as well as their physical symptoms, once they are gently made aware of this connection. Once the patient is aware of this, the psychologic currency of the symptom loses value, and the symptom may be allowed to improve.

  • Consider hospital admission: The patient may not return for follow-up after being given a psychiatric diagnosis. A more rapid completion of the diagnostic workup is possible. In addition, a parallel investigation of physical and psychologic factors can concomitantly be pursued. One caveat to note is that the clinical situation may be worsened by providing the patient with the secondary gain he or she is seeking.
  • Avoid invasive diagnostic and therapeutic interventions.
  • Tactful presentation of the diagnosis to the patient includes the following:
    • Avoid giving the patient the impression that you feel there is nothing wrong with them.
    • Do not inform the patient of the diagnosis on the first encounter.
    • Reassure the patient that the symptoms are very real despite the lack of a definitive organic diagnosis.
    • Provide socially acceptable examples of diseases that often are deemed stress-related (eg, peptic ulcer disease, hypertension).
    • Provide common examples of emotions producing symptoms (eg, queasy stomach when talking in front of an audience, heart racing when asking someone for a date).
    • Provide examples of how the subconscious influences behavior (eg, nail biting, pacing, foot tapping).
    • Provide reassurance that no evidence of an underlying neurological disorder is present based on the tests that were performed and that the prognosis for recovery is very good.
    • Provide positive reinforcement that the symptoms can improve spontaneously.
    • Inform patients that the symptoms are not volitional, and no one believes that they are faking.
    • Provide a graceful way for the patient to improve from the symptoms. (Allow for the symptom to get better over time, just as an organic entity might improve.) This is perhaps the most important point. A patient admitted to the neurology ward with a psychogenic gait disorder should not be discharged suddenly once any mild improvement is seen. It may be the better part of valor to hold a patient a day or so to ensure that the treatment is taking hold.
  • No specific pharmacologic therapy is available for conversion disorder; however, medications for comorbid mood and anxiety disorders should be considered. Care should be taken to avoid dependence-producing psychotropic agents.
  • Physical therapy may be warranted and is often helpful in providing the patient an ego-syntonic way out as they are being provided a benign treatment to which they can respond and improve.[31, 32]
  • Institute patient and family education sensitively.
  • Regular short follow-up appointments with a neurologist or a psychiatrist should be provided to limit ED visits and unnecessary diagnostic or invasive tests.
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Consultations

A multidisciplinary approach to the treatment of conversion disorder is beneficial.[28]

  • Neurologist: This is the primary evaluation where a conversion disorder is differentiated from neurologic diseases.
  • Cardiologist: Consultation is warranted if the patient has episodic alterations of consciousness due to concern over cardiogenic syncope.
  • Physical therapist: Consultation may be warranted for those with motor or gait symptoms.[31]
  • Psychiatrist: This is generally indicated when the symptoms persist. This can aid in identification of psychologic stressors symbolically linked to the symptoms and other risk factors for conversion disorder. The patient must be informed about the consultation before the psychiatrist does the interview. Psychiatric treatments that have demonstrated effectiveness include the following:
    • Insight Oriented Supportive therapy: Offers the client support and helps the patient to gain insight into their condition and possible triggers.
    • Behavioral therapy: Examines the patient's symptoms and teaches techniques to help them better cope and alleviate the symptoms (eg, biofeedback techniques). This is ideal for those lacking intelligence and insight.
    • Psychodynamic therapy: This may be used further in the treatment process as a means to help the patient gain insight. However, patients with borderline intelligence, lack of motivation or introspection capabilities, important secondary gains, or those with a tendency for behavioral acting out are likely poor candidates.
  • Psychologist: Psychosocial interventions that may be helpful include paradoxical intention therapy and hypnosis.[14]
    • Family therapy: Interactions and communication within the family are emphasized rather than only focusing on the individual patient.[1]
  • Whatever the type of therapy, the most important element is a good relationship with a confident, supportive therapist.
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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, Department of Neurology, Walter Reed Army Medical Center, National Naval Medical Center

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 VirtualPsych, LLC

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

Disclosure: pfizer Consulting fee Speaking and teaching

Alexis Llewellyn, PhD  Psychologist, Private Practice

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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 None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft 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.

Acknowledgments

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

  2. 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].

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

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

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

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

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

  8. 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. Spring 2008;19(1):101-7. [Medline].

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

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

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

  12. 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. Jul 2003;74(7):897-900. [Medline].

  13. Somatoform Disorders. In: 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].

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

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

  16. 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. Aug 2007;11(1):77-84. [Medline].

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

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

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

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

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

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

  23. 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. Dec 1998;245(12):797-802. [Medline].

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

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

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

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

  28. 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].

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

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

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

  32. 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.

  33. 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.

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

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

  36. 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. Aug 2007;11(1):77-84. [Medline].

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

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

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

  40. 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. Mar 1992;1(1):27-32. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  56. 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].

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

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

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

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

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

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

  63. 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.

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

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

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

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

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

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

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