eMedicine Specialties > Emergency Medicine > Psychosocial

Conversion Disorder: Follow-up

Author: Seth Powsner, MD, Professor of Psychiatry and Emergency Medicine, Yale University School of Medicine; Medical Director, Crisis Intervention Unit, Section of Emergency Medicine, Yale-New Haven Hospital
Coauthor(s): Susan E Dufel, MD, FACEP, Program Director, Associate Professor, Department of Traumatology and Emergency Medicine, Division of Emergency Medicine, University of Connecticut School of Medicine
Contributor Information and Disclosures

Updated: May 1, 2009

Follow-up

Further Outpatient Care

  • Any patient diagnosed with a conversion reaction in the ED should be encouraged to pursue psychiatric follow-up. This can be suggested as a way to reduce and manage stress and mitigate exacerbation of physical symptoms (side-stepping arguments about etiology of symptoms). Psychiatric follow-up is especially helpful for rare cases of more serious psychiatric syndromes presenting to an emergency department with physical symptoms.
  • Many patients have spontaneous remission after outpatient psychotherapy or suggestive therapy.
  • As of yet, there are no well-established treatment regimens for conversion disorder. There has been more success with the other somatoform disorders.

Transfer

  • All transfers must comply with Consolidated Omnibus Budget Reconciliation Act (COBRA)/Emergency Medical Transfer and Active Labor Act (EMTALA) regulations (see COBRA Laws and EMTALA).

Complications

  • Errors in diagnosis of conversion disorder are not uncommon. With newer diagnostic testing, instances of false-positive diagnoses of conversion disorder in which a neurological disease is later identified are around 4%.
  • Recent studies have found a variety of organic diseases in patients who were initially diagnosed with conversion disorder. In one case report, a woman reporting leg weakness and back pain was subsequently diagnosed with sporadic Creutzfeldt-Jakob disease.9 Other patients with underlying psychiatric illnesses were found to have disk herniations, epidural abscesses, or cerebral hemorrhages. In another case series, 5 patients were identified as having sarcoma-induced osteomalacia, cerebellar medulloblastoma, Huntington chorea, transverse myelitis, and lower extremity dystonia. Although these case reports were rare, the initial diagnosis of conversion disorder without a complete neurologic examination, appropriate imaging, and other diagnostic testing should be discouraged.

Prognosis

  • Prognostic studies differ in outcome, with recovery rates ranging from 15-74%. Factors associated with favorable outcomes are male gender, acute onset of symptoms, precipitation by a stressful event, good premorbid health, and an absence of organic or psychiatric disorder.10
  • Many patients with conversion reactions have spontaneous remission or demonstrate marked or complete recovery after brief psychotherapy.

Miscellaneous

Medicolegal Pitfalls

  • Underlying organic disease may be present in patients with conversion disorder. Errors in diagnosis may be as much as 25%, especially with the limited time and testing available in the ED. If uncertain as to the etiology of the patient's symptoms or uncomfortable with a complicated neurologic presentation, seek appropriate neurologic and psychiatric consultation.
 


More on Conversion Disorder

Overview: Conversion Disorder
Differential Diagnoses & Workup: Conversion Disorder
Treatment & Medication: Conversion Disorder
Follow-up: Conversion Disorder
References
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References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisions. Washington DC: American Psychiatric Association; 2000.

  2. Brown RJ, Cardena E, Nijenhuis E, et al. Should conversion disorder be reclassified as a dissociative disorder in DSM V?. Psychosomatics. Sep-Oct 2007;48(5):369-78. [Medline].

  3. Ford CV, Folks DG. Conversion disorders: an overview. Psychosomatics. May 1985;26(5):371-4, 380-3. [Medline].

  4. Mace CJ. Hysterical conversion. I: A history. Br J Psychiatry. Sep 1992;161:369-77. [Medline].

  5. Breuer J, Freud S. Studies on hysteria. In: Translated from the German and edited by James Strachey, in collaboration with Anna Freud, assisted by Alix Strachey and Alan Tyson. Case I Fräulein Anna O. (Breuer). New York: Basic Books; 1957:21.

  6. Stone J, Zeman A, Simonotto E, et al. FMRI in patients with motor conversion symptoms and controls with simulated weakness. Psychosom Med. Dec 2007;69(9):961-9. [Medline].

  7. Liepert J, Hassa T, Tuscher O, et al. Electrophysiological correlates of motor conversion disorder. Mov Disord. Sep 10 2008;[Medline].

  8. Binzer M, Andersen PM, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry. Jul 1997;63(1):83-8. [Medline].

  9. Solvason HB, Harris B, Zeifert P, et al. Psychological versus biological clinical interpretation: a patient with prion disease. Am J Psychiatry. Apr 2002;159(4):528-37. [Medline].

  10. Binzer M, Kullgren G. Motor conversion disorder. A prospective 2- to 5-year follow-up study. Psychosomatics. Nov-Dec 1998;39(6):519-27. [Medline].

  11. Drake ME Jr. Conversion hysteria and dominant hemisphere lesions. Psychosomatics. Nov-Dec 1993;34(6):524-30. [Medline].

  12. Dula DJ, DeNaples L. Emergency department presentation of patients with conversion disorder. Acad Emerg Med. Feb 1995;2(2):120-3. [Medline].

  13. Glick TH, Workman TP, Gaufberg SV. Suspected conversion disorder: foreseeable risks and avoidable errors. Acad Emerg Med. Nov 2000;7(11):1272-7. [Medline].

  14. Hodgman CH. Conversion and somatization in pediatrics. Pediatr Rev. Jan 1995;16(1):29-34. [Medline].

  15. Kent DA, Tomasson K, Coryell W. Course and outcome of conversion and somatization disorders. A four-year follow-up. Psychosomatics. Mar-Apr 1995;36(2):138-44. [Medline].

  16. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. Dec 2007;69(9):881-8. [Medline].

  17. Lloyd GG. Acute behaviour disturbances. J Neurol Neurosurg Psychiatry. Nov 1993;56(11):1149-56. [Medline].

  18. Mai FM. "Hysteria" in clinical neurology. Can J Neurol Sci. May 1995;22(2):101-10. [Medline].

  19. McCahill ME. Somatoform and related disorders: delivery of diagnosis as first step. Am Fam Physician. Jul 1995;52(1):193-204. [Medline].

  20. Schwingenschuh P, Pont-Sunyer C, Surtees R, et al. Psychogenic movement disorders in children: A report of 15 cases and a review of the literature. Mov Disord. Aug 29 2008;[Medline].

  21. Sharma P, Chaturvedi SK. Conversion disorder revisited. Acta Psychiatr Scand. Oct 1995;92(4):301-4. [Medline].

  22. Shorter E. The borderland between neurology and history. Conversion reactions. Neurol Clin. May 1995;13(2):229-39. [Medline].

  23. Speed J. Behavioral management of conversion disorder: retrospective study. Arch Phys Med Rehabil. Feb 1996;77(2):147-54. [Medline].

  24. 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].

  25. Teasell RW, Shapiro AP. Misdiagnosis of conversion disorders. Am J Phys Med Rehabil. Mar 2002;81(3):236-40. [Medline].

  26. Tobiano PS, Wang HE, McCausland JB, et al. A case of conversion disorder presenting as a severe acute stroke. J Emerg Med. Apr 2006;30(3):283-6. [Medline].

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Further Reading

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Keywords

conversion disorder, conversion reactions, hysteria, depression, somatoform disorder, psychiatric condition, psychological conflict, psychological need, paralysis, sensory disturbances, pseudoseizures, involuntary movements, maladaptive response to stress, psychosocial stress, organic brain disorder, la belle indifférence, optokinetic nystagmus, monocular diplopia, triplopia, field defects, tunnel vision, bilateral blindness, astasia-abasia

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Contributor Information and Disclosures

Author

Seth Powsner, MD, Professor of Psychiatry and Emergency Medicine, Yale University School of Medicine; Medical Director, Crisis Intervention Unit, Section of Emergency Medicine, Yale-New Haven Hospital
Seth Powsner, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Medical Association, American Psychiatric Association, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Susan E Dufel, MD, FACEP, Program Director, Associate Professor, Department of Traumatology and Emergency Medicine, Division of Emergency Medicine, University of Connecticut School of Medicine
Susan E Dufel, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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