Conversion Disorder in Emergency Medicine Follow-up

  • Author: Seth Powsner, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Apr 14, 2011
 

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.
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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).
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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%.
  • Authors have reported various 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.[22] 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.[23] 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.[24]
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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.[25]
  • Many patients with conversion reactions have spontaneous remission or demonstrate marked or complete recovery after brief psychotherapy.
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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, Emergency Department, Yale-New Haven Hospital

Seth Powsner, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Technology in Psychiatry, American Medical Association, American Psychiatric Association, and Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI, Columbus, Ohio

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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.

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, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

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.

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

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

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

  6. 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.

  7. 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].

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

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

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

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

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

  13. 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].

  14. 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].

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

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

  17. 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].

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

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

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

  21. Shapiro AP, Teasell RW. Behavioural interventions in the rehabilitation of acute v. chronic non-organic (conversion/factitious) motor disorders. Br J Psychiatry. Aug 2004;185:140-6. [Medline].

  22. 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].

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

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

  25. 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].

  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].

  27. 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].

 
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