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Conversion Disorders Treatment & Management

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

Medical Care

Current understanding of the phenomenon of conversion disorder implicates some role of the unconscious in the pathophysiology of this condition.[12, 33] 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.

Hospital admission may be considered in some cases. For example, for a patient that seems likely to not return for follow-up after being given a psychiatric diagnosis. A more rapid completion of the diagnostic workup is possible in the hospital setting. 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.[34, 35]

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.[33]

  • 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. [34]
  • 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. [16]
    • Family therapy: Interactions and communication within the family are emphasized rather than only focusing on the individual patient.[2]
  • 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, 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.

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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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