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Conversion Disorder in Emergency Medicine

  • Author: Seth Powsner, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Nov 09, 2015
 

Background

Conversion disorder (functional neurological symptom disorder) is classified as one of the somatic symptom and related disorders in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fifth Edition (DSM-5).[1, 2, 3] (These were formerly known as somatoform disorders in DSM-IV-TR).[4] Although defined as a condition that presents as an alteration or loss of a physical function suggestive of a physical disorder, conversion disorder is presumed to be the expression of an underlying psychological conflict or need.

The critical psychological conflict or stress may not be apparent initially, but it becomes evident in the course of obtaining a patient’s history: ideally, it is a psychological factor related symbolically and temporally to symptom onset. Conversion symptoms are presumed to result from an unconscious process. (Conscious/intentional production of physical symptoms is classified as factitious disorder or malingering.) Conversion symptoms are not considered to be under voluntary control, and, should not be explained by any physical disorder or known pathological mechanism (after appropriate medical evaluation).

Though classified with somatic symptom/somatoform disorders in DSM-III through DSM-5, conversion disorder is classified as a dissociative disorder in ICD-10, keeping its long association with hysteria (Dissociative Disorders in DSM).[5, 6] Clinical descriptions of conversion disorder date to almost 4000 years ago; the Egyptians attributed symptoms to a "wandering uterus." In the 19th century, Paul Briquet described the disorder as a dysfunction of the CNS.[7, 8] Freud first used the term conversion to refer to the development of a somatic symptom to help bind anxiety around a repressed conflict.[9] In current practice, the term has made it into the popular press.[10]

For related information, see Medscape's Psychiatry and Mental Health Specialty page.

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Pathophysiology

Presenting symptoms can range far across the field of clinical neurology. Conversion reactions usually approximate lesions in the nervous system’s voluntary motor or sensory pathways. Symptoms most commonly reported are weakness, paralysis, pseudoseizures, involuntary movements (eg, tremors), and sensory disturbances. These losses or distortions of neurologic function cannot adequately be accounted for by organic disease.

Functional MRI (fMRI) and transcranial magnetic stimulation (TMS) studies have shown different activation patterns in patients with conversion symptoms and healthy control subjects; this is in keeping with the "involuntary" nature of conversion symptoms.[11, 12, 13, 14]

Patients whose symptoms are limited to pain or sexual functioning are not classified under conversion disorder; likewise, patients already classified as demonstrating somatization disorder or schizophrenia are also not classified under conversion disorder.

The DSM-5 diagnostic criteria for conversion disorder are as follows:[1]

  • One or more symptoms of altered voluntary motor or sensory function.
  • Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
  • The symptom or deficit is not better explained by another medical or mental disorder.
  • The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

According to psychodynamic theory, conversion symptoms develop to defend against unacceptable impulses.[9] The primary gain, that is to say the purpose of a conversion symptom is to bind anxiety and keep a conflict internal. A fairly transparent example would be leg paralysis after an equestrian competitor is thrown from his or her horse. The symptom has a symbolic value that is a representation and partial solution of a deep-seated psychological conflict: to avoid running away like a coward, and yet to avoid being thrown again.

According to learning theory, conversion disorder symptoms are a learned maladaptive response to stress. Patients achieve secondary gain by avoiding activities that are particularly offensive to them, thereby gaining support from family and friends, which otherwise may not be offered.[15]

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Epidemiology

Frequency

United States

True conversion reaction is rare.[16, 17] Predisposing factors include extreme psychosocial stress, and perhaps, rural upbringing. Some psychiatrists suspect that western society has incorporated Freudian notions of unconscious motivations and conflicts: conversion reactions have become too obvious to serve their purpose.

  • The incidence of individual persistent conversion symptoms is estimated to be 2-5/100,000 per year. [1]
  • Cultural factors may play a significant role. [18] Symptoms that might be considered a conversion disorder in the United States may be a normal expression of anxiety in other cultures.
  • One study reports that conversion disorder accounts for 1.2-11.5% of psychiatric consultations for hospitalized medical and surgical patients.

International

At the National Hospital in London, the diagnosis was made in 1% of inpatients.[19] Iceland's incidence of conversion disorder is reported to be 15 cases per 100,000 persons.

Mortality/Morbidity

Patients diagnosed with conversion disorder may go on to demonstrate serious, traditional medical illness. This has been happening less and less often over the years (29% in 1950s down to 4% in 1990s). Unfortunately, emergency physicians may find themselves sorting out new neurologic symptoms in settings of terrible time pressure: populations statistics may be of little reassurance for any specific individual.

Sex- and age-related demographics

Sex ratio is not known although it has been estimated that women patients outnumber men by 6:1. According to DSM-5, conversion disorder is two to three times more common in females.[1]

Conversion disorder may present at any age but is rare in children younger than 10 years or in persons older than 35 years.[20]

In a University of Iowa study of 32 patients with conversion disorder, however, the mean age was 41 years with a range of 23-58 years.[21]

In pediatric patients, incidence of conversion is increased after physical or sexual abuse. Incidence also increases in those children whose parents are either seriously ill or have chronic pain.[22]

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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 Medical Association, American Psychiatric Association, Sigma Xi, American Association for Technology in Psychiatry, American Association for Emergency Psychiatry

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.

Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, 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, Council of Emergency Medicine Residency Directors, American College of Emergency Physicians, American Medical Association, Phi Beta Kappa, 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 for 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 Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of Susan E Dufel, MD, FACEP, to the original writing and development of this article.

References
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