Conversion Disorder

Conversion disorder (CD), also called functional neurologic symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Patients are typically impaired in their social and professional life, but can also be inappropriately unconcerned with their symptoms. Treatment centers around patient education and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Epidemiology and Etiology

Epidemiology

  • Estimated prevalence varies, with the highest prevalence found in neurology clinics.
  • More common in women and patients of low socioeconomic status 
  • Manifests in adolescence and early adulthood
  • More prevalent in patients with neurologic or psychiatric comorbidities

Etiology

  • Exact etiology is unknown. 
  • Thought to be a combination of psychodynamic, developmental, biological, and social pathology 
  • Stressful life events have been shown to be potential triggers for the physical symptoms. 
  • There is evidence for impaired communication between the amygdala and supplementary motor area, causing excessive cortical arousal.

Clinical Presentation

Conversion disorder presents with neurologic symptoms that are inconsistent with structural disease. 

  • Patients may present with sensory complaints that do not map to known nerve distributions (e.g., weakness/paresthesia in the entire leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg).
  • Patients showing non-epileptiform seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures may have abnormal features (eyes closed tightly) and should be evaluated with video EEG.

Common motor symptoms:

  • Non-epileptic seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures (psychogenic seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures)
  • Tremor (psychogenic tremor)
  • Impaired gait
  • Weakness/paralysis

Common sensory symptoms:

  • Anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
  • Vision impairment (blindness, decreased visual field)
  • Hearing impairment
  • Hallucinations

Diagnosis

General approach

  • Associated with so-called la belle indifference: Patients appear to be inappropriately unconcerned with their symptoms given their level of disability.
  • History and physical exam should begin from the patient in the waiting room until the patient leaves the office, as inconsistencies are likely to be found.
  • Baseline investigations may include:
    • CBC
    • Basic metabolic panel
    • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests
    • Thyroid panel
    • Urinalysis
    • Toxicology screen
    • Imaging may be required.

DSM-V diagnostic criteria

  • At least 1 impairment in voluntary motor or sensory function
  • Clinical findings show evidence of incongruence between the symptoms and recognized exam findings.
  • Symptoms cannot be better explained by another disorder. 
  • Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of function.

Specific findings

The following 2 tests may help differentiate conversion disorder from organic disease, if the respective neurological deficits are present.

  • Hoover’s sign: 
    • Diagnostic test to differentiate organic from non-organic leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg paresis
    • Patient must be supine; examiner cups both hands under the patient’s heels.
    • Patient is instructed to flex the hip of the non-paretic leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
    • Examiner should feel the contralateral heel press down into their palm. 
    • When the patient is asked to flex the hip of the paretic leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, the examiner should similarly feel the contralateral heel press down into their palm. 
    • Positive: failure of the contralateral heel to depress → hip girdle is not being activated to lift the paretic leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg → suggestive of conversion disorder 
  • Drop arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm test: 
    • While patient is lying down, raise the impaired arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm above the patient and release. 
    • In patients with conversion disorder, the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm will not hit the face.
Table: Different tests to help differentiate conversion disorder from organic neurological impairment
Symptom Physical exam maneuver Characteristic findings for conversion disorder
Tremor Distraction Tremor intensity decreases.
Weakness/paralysis
  • Hoover’s sign
  • Drop arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm test
  • Hoover’s sign: positive
  • Drop arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm test: Arm will not hit the face.
Impaired gait Chair test Gait is impaired but patient is able to rock chair back and forth while sitting down.
Anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts Dermatome testing Testing of loss of sensation does not follow dermatome patterns.
Blindness Fingertip touching test
  • Patient is asked to bring the tips of their index fingers together.
  • Difficulties completing the task are suggestive of conversion disorder.
  • A person with true blindness does not have difficulty completing the task (proprioception more important than visual field).
Deafness Startle test Patient becomes startled in response to unexpected noise.
Table: Features of conversion disorder compared with similar conditions
Symptoms Excessive worry Exam findings
Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder + +
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder +
Conversion disorder + Atypical

Management and Prognosis

Management

  • Clinicians must assure patients that their symptoms are real, but do not represent irreversible damage.  
  • Establishing good rapport as well as working in a multidisciplinary team is important. 
  • Treatment of choice is psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, usually CBT. 
  • Physical therapy for evaluation and treatment of underlying distress.
  • Utilize pharmacotherapy when there are other comorbid psychiatric illnesses such as depression or anxiety.

Prognosis

  • Relatively poor with low response to current treatment modalities 
  • Higher patient confidence in physician as well as shorter duration of symptoms are associated with better outcome.

Differential Diagnosis

  • Myasthenia gravis Myasthenia Gravis Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by weakness and fatigability of skeletal muscles caused by dysfunction/destruction of acetylcholine receptors at the neuromuscular junction. MG presents with fatigue, ptosis, diplopia, dysphagia, respiratory difficulties, and progressive weakness in the limbs, leading to difficulty in movement. Myasthenia Gravis (MG): an autoimmune neuromuscular disorder caused by dysfunction of acetylcholine receptors at the neuromuscular junction. The condition presents with fatigue, ptosis, diplopia, dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming "stuck." Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia, respiratory difficulties, and progressive weakness in the limbs leading to difficulty in movement. Diagnosis is established based on clinical presentation as well as detection of antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins and electrophysiologic studies, which are negative in CD.
  • Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder (SSD): a condition in which patients present with 1 or multiple somatic complaints and excessive thoughts and concern about the severity of their symptoms. Management is with CBT. Somatic symptom disorder Somatic symptom disorder Somatic symptom disorder (SSD) is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Somatic Symptom Disorder is a diagnosis of exclusion as there are no exam findings, unlike in CD.  
  • Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder: a condition characterized by prolonged and exaggerated concern about one’s health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of serious medical conditions. Management is with CBT. Those with CD do not exhibit the excessive worry found in illness anxiety disorder.  

References

  1. Ali, S, Jabeen, S, Pate, RJ, Shahid, M, Chinala, S, Nathani, M, & Shah, R. (2015). Conversion Disorder- Mind versus Body: A Review. Innovations in clinical neuroscience, 12(5-6), 27–33.
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author
  3. Mehndiratta, MM, Kumar, M, Garg, H, & Pandey, S. (2014). Hoover’s sign: Clinical relevance in Neurology [Abstract]. Journal of Postgraduate Medicine, 60(3), 297-299.
  4. Peeling JL, Muzio MR. Conversion Disorder. (2020). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551567/
  5. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 13, Psychosomatic medicine, pages 465-503. Philadelphia, PA: Lippincott Williams and Wilkins.
  6. Harvey, SB, Stanton, BR, & David, AS. (2006). Conversion disorder: Towards a neurobiological understanding. Neuropsychiatric Disease and Treatment, 2(1), 13–20.

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