Conversion Disorder in Emergency Medicine Clinical Presentation

Degree of impairment usually is marked and interferes with daily life activities. Prolonged loss of function may produce organic complications such as disuse atrophy or contractures.

Weakness, paralysis, pseudoseizures, involuntary movements (eg, tremors), and sensory disturbances (eg, aphonia, deafness, blindness) are the most frequent complaints. Symptoms often enable patients to avoid an unpleasant situation at home or work, attract attention, or gain support from others. This may become evident through careful questioning.

The symptom must not be under voluntary control. Determining the symptom may be difficult, since it usually cannot be identified by observation. Features suggestive of voluntary control consist of variability, inconsistency, obvious and immediate benefit, as well as a personality that may suggest dishonesty and opportunism. Symptoms, if voluntary, tend to be self-limited and of brief duration.

La belle indifférence was considered a classic feature of conversion disorder. It is characterized by the inappropriate and paradoxical absence of distress despite the presence of an unpleasant symptom. Patients often deny emotional difficulty. Unfortunately, la belle indifférence, histrionic personality, and secondary gain are clinical features that appear to have no diagnostic significance. They can easily be absent in patients with conversion disorder; they can be easily be present in patients with traditional neurologic disorder.

One study reported 5 patients with hysterical conversion reactions after injury or infarction to the left cerebral hemisphere.^[16]

Absence of a physical disorder is an important diagnostic feature. Individuals with conversion disorder often have physical signs but lack objective neurological signs to substantiate their symptoms.

Weakness

Weakness usually involves whole movements rather than muscle groups. Weakness affects the extremities more often than ocular, facial, or cervical movements.

With the use of various clinical techniques, weakness of one limb can be demonstrated to cause contraction of opposing muscle groups. Discontinuous resistance during testing of power or give-way weakness may exist. Muscle wasting is absent, and reflexes are normal.

Sensory symptoms

Sensory loss or distortion often is inconsistent when tested on more than one occasion and is incompatible with peripheral nerve or root distribution.

Discrete patches of anesthesia or hemisensory loss that stop in the midline may be present.

Classic dermatomes in patients with numbness usually are not followed.

Visual symptoms

Visual symptoms include monocular diplopia, triplopia, field defects, tunnel vision, and bilateral blindness associated with intact pupillary reflexes.

Optokinetic nystagmus may be observed in patients with apparent blindness when exposed to a rotating striped drum.

Gait disturbances

Astasia-abasia is a motor coordination disorder characterized by the inability to stand despite normal ability to move legs when lying down or sitting.

Patients walk normally if they think they are not being observed.

Occasionally, while being observed, patients actively attempt to fall. This contrasts with those patients with organic disease who attempt to support themselves.

Pseudoseizures

During an attack, marked involvement of the truncal muscles with opisthotonos and lateral rolling of the head or body is present. All 4 limbs may exhibit random thrashing movements, which may increase in intensity if restraint is applied.

Cyanosis is rare unless patients deliberately hold their breath.

Reflexes (eg, pupillary, corneal) are retained but may be difficult to test due to tightly closed lids.

Tongue biting and incontinence are rare unless the patient has some degree of medical knowledge about the natural course of the disease.

In contrast to true seizures, pseudoseizures primarily occur in the presence of other people and not when the patient is alone or asleep.

• True etiology is unknown. Most clinicians presume conversion reactions are caused by previous severe stress, emotional conflict, or an associated psychiatric disorder.
• Many studies confirm high incidence of depression in patients with conversion disorder. As many as half of these patients have personality disorders or display hysterical traits.^[17]
• In children, conversion disorder often is observed following physical or sexual abuse.
• Children who have family members with a history of conversion reactions are more likely to suffer from conversion disorder. In addition, if family members are seriously ill or in chronic pain, children are more likely to be affected.