Conversion disorder is a mental disorder characterized by symptoms that
suggest a neurologic or general medical condition but that cannot
be fully explained by a neurologic or mental disorder. Other synonyms
include psychogenic disorder, pseudoneurologic syndrome, or hysterical neurosis.
Conversion disorder is one of several types of somatoform disorder
(conversion disorder, hypochondriasis, somatization disorder, somatoform
pain disorder) that is characterized by persistent physical symptoms
for which no cause can be found. For a diagnosis of conversion disorder
to be made, the following five criteria must be met1:
1. A symptom is expressed in which there is a change
or loss of physical function suggesting a physical disorder.
2. The patient has experienced a recent psychological stressor or
3. The patient unconsciously produces the symptom.
4. The symptom cannot be explained by a known organic etiology or culturally
sanctioned response pattern.
5. The symptom is not limited to pain or sexual dysfunction.
An illustrative example involves the case of a young wife who
is scheduled to visit her debilitated father in the hospital. His
recent diagnosis of cancer has left her distraught, and the sight
of him depresses her greatly. On the morning of her visit, she suddenly
This example typifies a conversion
disorder in which conflict is caused by the patient’s intense,
but psychically unacceptable, urge to avoid a required action (in
this case, visiting her father). The physical symptom (blindness)
allows expression of the urge (how can she drive there if she is
blind?) without consciously confronting the feelings that led to
the wish. At the same time, the symptom imposes morbidity as a punishment
for the wish. Often, the presenting symptom will have a symbolic relationship
to the conflict, but this is not always the case. In this case,
the sight of her father is distressing; and therefore, loss of sight
is the chief complaint.
Conversion disorders are often thought of as
nonverbal exertions of control on the environment. Two mechanisms
are responsible for the symptoms. The first is primary gain,
in which the symptom allows patients to avoid confronting their
uncomfortable feelings. The second is secondary gain,
in which uncomfortable situations are avoided and support is given that
might not normally be available. In our example, secondary gain would
occur if the patient’s husband then stayed home from work
to tend to his “blind” wife.
Conversion disorders are described as rare, and
most agree that the incidence is declining. Cases predominantly
involve neurologic and orthopedic manifestations and are seen in
the military during times of war, in victims of industrial accidents,
and in victims of violence. Conversion disorders are much more frequent
in women, accounting for most cases in some series, than in men.
The most common ages of presentation are adolescence or early childhood,
although other age groups are affected.2 A recent
large Australian study found the average age of onset to be 11.8 years
old with an incidence of 3 in 100,000 children.3 Conversion
disorders are more prevalent in rural, lower socioeconomic, and
less educated populations. Other predisposing factors include medical
illness, depression, anxiety, schizophrenia, somatization disorder,
dependent personality disorder (5% to 21% of patients),
borderline personality disorder, and passive aggressive personality
Patients with conversion disorder commonly report a history of
physical or sexual abuse.5
Conversion disorders usually present as a single symptom with
a sudden onset related to a severe stress. The most common sources
of the stressors involve work or family situations. Precise history
taking should focus on how the problem affects the patient and the
surrounding events at time of onset. It may be necessary to interview
the patient and family separately to confirm diagnostic suspicions.
The most reliable diagnostic criterion for conversion disorder is
a history of the disorder or a somatization disorder (each found
in one third of cases). Symptoms may vary in cases of recurrence.2,4,6 Motor
complaints, usually involving voluntary muscles, are more common
than sensory complaints.2,4,6
Classic symptoms of conversion disorders include
paralysis, aphonia, seizures, coordination disturbances, akinesia,
dyskinesia, blindness, tunnel vision, anosmia, anesthesia, and paresthesia. Pseudoseizures represent
10% to 40% of conversion disorders referred to
psychiatrists. This group often has coexistent depression, which,
if treated, resolves the conversion disorder as well.5 The
current trend is to refer to this group as having “nonepileptic
seizures,” as patients are much more accepting and cooperative
when given this diagnosis versus being labeled as “pseudoseizures” implying
voluntary activity.5 Patients may describe their condition
with surprising lack of concern, considering the severity of the symptom
(la belle indifférence). This was previously
thought to be a hallmark of the disorder, but it is absent in about
half of cases and is found just as often in patients with organic
disease. It is no longer considered diagnostic.3,7
Diagnosis is made first and foremost by
ruling out organic pathology. Absence of a medical condition does
not necessarily support the diagnosis of conversion disorder, because
the appropriate psychological criteria also must be met. Suspicion
for the disorder should arise when no physical findings related
to the symptom are found or the examination is not consistent with
known anatomic or pathophysiologic states. Several techniques that
can be used in the physical examination are helpful in testing for
true neurologic deficits (Table 288-1 and Figure 288-1). Appropriate laboratory and
ancillary studies should be ordered to confirm suspected organic
disease. However, organic disease may be present concurrently with
conversion disorder.8 Recent studies, utilizing
functional imaging, support a neurophysiologic basis for conversion triggered
by psychological processes. These studies suggest that neural circuits
linking volition, movement, and perception are disrupted in conversion
Table 288-1 Testing
Techniques for Conversion Disorder
| Save Table
Table 288-1 Testing
Techniques for Conversion ...
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