Conversion Disorder
Conversion Disorder
Definition
Conversion disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, also known as the DSM-IV-TR as a mental disorder whose central feature is the appearance of symptoms affecting the patient’s senses or voluntary movements that suggest a neurological or general medical disease or condition. Somatoform disorders are marked by persistent physical symptoms that cannot be fully explained by a medical condition, substance abuse, or other mental disorder, but rather seem to stem from psychological issues or conflicts. The DSM-IV-TR classifies conversion disorder as one of the somatoform disorders, first classified as a group of mental disorders by the DSM III in 1980. Other terms that have sometimes been used for conversion disorder include pseudoneurologic syndrome, hysterical neurosis, and psychogenic disorder.
Conversion disorder is a major reason for visits to primary care practitioners. One study of health care utilization estimated that 25-72% of office visits to primary care doctors involved psychological distress that takes the form of somatic (physical) symptoms. Another study estimated that at least 10% of all medical treatments and diagnostic services were ordered for patients with no evidence of organic disease. Conversion disorder carries a high economic price tag. Patients who convert their emotional problems into physical symptoms spend nine times as much for health care as people who do not somatosize; and 82% of adults with conversion disorder stop working because of their symptoms. The annual bill for conversion disorder in the United States comes to $20 billion, not counting absenteeism from work and disability payments.
Description
Conversion disorder has a complicated history that helps to explain the number of different names for it. Two eminent neurologists of the nineteenth century, Jean-Martin Charcot in Paris, France, and Josef Breuer in Vienna, Austria, were investigating what was then called hysteria, a disorder primarily affecting women (the term “hysteria” comes from the Greek word for uterus or womb). Women diagnosed with hysteria had frequent emotional outbursts and a variety of neurologic symptoms, including paralysis, fainting spells, convulsions, and temporary loss of sight or hearing. Pierre Janet (one of Charcot’s students), and Breuer independently came to the same conclusion about the cause of hysteria—that it resulted from psychological trauma. Janet, in fact, coined the term “dissociation” to describe the altered state of consciousness experienced by many patients who were diagnosed with hysteria.
The next stage in the study of conversion disorder was research into the causes of “combat neurosis” in World War I (1914-1918) and World War II (1939-1945). Many of the symptoms observed in “shell-shocked” soldiers were identical to those of “hysterical” women. Two of the techniques still used in the treatment of conversion disorder, hypnosis and narcotherapy, were introduced as therapies for combat veterans. The various terms used by successive editions of the DSM and the ICD (the European equivalent of DSM) for conversion disorder reflect its association with hysteria and dissociation. The first edition of the DSM (1952) used the term “conversion reaction.” The DSM-II (1968) called the disorder “hysterical neurosis (conversion type),” and the DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) have all used the term “conversion disorder.” ICD-10 refers to it as “dissociative (conversion) disorder.”
DSM-IV-TR (2000) specifies six criteria for the diagnosis of conversion disorder. They are:
- The patient has one or more symptoms or deficits affecting the senses or voluntary movement that suggest a neurological or general medical disorder.
- The onset or worsening of the symptoms was preceded by conflicts or stressors in the patient’s life.
- The symptom is not faked or produced intentionally.
- The symptom cannot be fully explained as the result of a general medical disorder, substance intake, or a behavior related to the patient’s culture.
- The symptom is severe enough to interfere with the patient’s schooling, employment, or social relationships, or is serious enough to require a medical evaluation.
- The symptom is not limited to pain or sexual dysfunction, does not occur only in the context of somatization disorder, and is not better accounted for by another mental disorder.
The DSM-IV-TR lists four subtypes of conversion disorder: conversion disorder with motor symptom or deficit; with sensory symptom or deficit; with seizures or convulsions; and with mixed presentation.
Although conversion disorder is most commonly found in individuals, it sometimes occurs in groups. One such instance occurred in 1997 in a group of three young men and six adolescent women of the Embera, an indigenous tribe in Colombia. The young people believed that they had been put under a spell or curse and developed dissociative symptoms that were not helped by antipsychotic medications or traditional herbal remedies. They were cured when shamans from their ethnic group came to visit them. The episode was attributed to psychological stress resulting from rapid cultural change.
Another example of group conversion disorder occurred in Iran in 1992. Ten girls out of a classroom of 26 became unable to walk or move normally following tetanus inoculations. Although the local physicians were able to treat the girls successfully, public health programs to immunize people against tetanus suffered an immediate negative impact. One explanation of group conversion disorder is that an individual who is susceptible to the disorder is typically more affected by suggestion and easier to hypnotize than the average person.
Causes and symptoms
Causes
The immediate cause of conversion disorder is a stressful event or situation that leads the patient to develop bodily symptoms as symbolic expressions of a long-standing psychological conflict or problem. One psychiatrist has defined the symptoms as “a code that conceals the message from the sender as well as from the receiver.”
Two terms that are used in connection with the causes of conversion disorder are primary gain and secondary gain. Primary gain refers to the lessening of the anxiety and communication of the unconscious wish that the patient derives from the symptom(s). Secondary gain refers to the interference with daily tasks, removal from the uncomfortable situation, or increased attention from significant others that the patient obtains as a result of the symptom(s).
Physical, emotional, or sexual abuse can be a contributing cause of conversion disorder in both adults and children. In a study of 34 children who developed pseudoseizures, 32% had a history of depression or sexual abuse, and 44% had recently experienced a parental divorce, death, or violent quarrel. At least one study, however, has found no consistent association between dissociation and sexual or physical abuse. In the adult population, conversion disorder may be associated with mobbing, a term that originated among European psychiatrists and industrial psychologists to describe psychological abuse in the workplace. One American woman who quit her job because of mobbing was unable to walk for several months. Adult males sometimes develop conversion disorder during military basic training. Conversion disorder may also develop in adults as a long-delayed aftereffect of childhood abuse. A team of surgeons reported on the case of a patient who went into a psychogenic coma following a throat operation. The surgeons found that she had been repeatedly raped as a child by her father, who stifled her cries by smothering her with a pillow.
Symptoms
In general, symptoms of conversion disorder are not under the patient’s conscious control, and are frequently mysterious and frightening to the patient. The symptoms usually have an acute onset, but sometimes worsen gradually.
The most frequent forms of conversion disorder in Western countries include:
- pseudoparalysis. In pseudoparalysis, the patient loses the use of half of his/her body or of a single limb. The weakness does not follow anatomical patterns and is often inconsistent upon repeat examination.
- pseudosensory syndromes. Patients with these syndromes often complain of numbness or lack of sensation in various parts of their bodies. The loss of sensation typically follows the patient’s notion of their anatomy, rather than known characteristics of the human nervous system.
- pseudoseizures. These are the most difficult symptoms of conversion disorder to distinguish from their organic equivalents. Between 5% and 35% of patients with pseudoseizures also have epilepsy. Electroencephalograms (EEGs) and the measurement of serum prolactin levels are useful in distinguishing pseudoseizures from epileptic seizures.
- pseudocoma. Pseudocoma is also difficult to diagnose. Because true coma may indicate a life-threatening condition, patients must be given standard treatments for coma until the diagnosis can be established.
- psychogenic movement disorders. These can mimic myoclonus, parkinsonism, dystonia, dyskinesia, and tremor. Doctors sometimes give patients with suspected psychogenic movement disorders a placebo medication to determine whether the movements are psychogenic or the result of an organic disorder.
- pseudoblindness. Pseudoblindness is one of the most common forms of conversion disorder related to vision. Placing a mirror in front of the patient and tilting it from side to side can often be used to determine pseudoblindness, because humans tend to follow the reflection of their eyes.
- pseudodiplopia. Pseudodiplopia, or seeing double, can usually be diagnosed by examining the patient’s eyes.
- pseudoptosis. Ptosis, or drooping of the upper eyelid, is a common symptom of myasthenia gravis and a few other disorders. Some people can cause their eyelids to droop voluntarily with practice. The diagnosis can be made on the basis of the eyebrow; in true ptosis, the eyebrows are lifted, whereas in pseudoptosis they are lowered.
- hysterical aphonia. Aphonia refers to loss of the ability to produce sounds. In hysterical aphonia, the patient’s cough and whisper are normal, and examination of the throat reveals normal movement of the vocal cords.
Psychiatrists working in various parts of the Middle East and Asia report that the symptoms of conversion disorder as listed by the DSM-IV and the ICD-10 do not fit well with the symptoms of the disorder most frequently encountered in their patient populations.
Demographics
The lifetime prevalence rates of conversion disorder in the general population are estimated to fall between 2.5 and 500 per 100,000 people. Differences among estimates reflect differences in the method of diagnosis as well as regional population differences. In terms of clinical populations, conversion disorder is diagnosed in 5–14% of general hospital patients; 1-3% of outpatient referrals to psychiatrists; and 5-25% of psychiatric outpatients. The frequency among clinical populations overall is reported between 20 and 120 per 100,000 patients.
Among adults, women diagnosed with conversion disorder outnumber men by a 2:1 to 10:1 ratio; among children, however, the gender ratio is closer to 1:1. Less-educated people and those of lower socioeconomic status are more likely to develop conversion disorder; race by itself does not appear to be a factor. There is, however, a major difference between the populations of developing and developed countries. In developing countries, the prevalence of conversion disorder may run as high as 31%.
Diagnosis
Conversion disorder is one of the few mental disorders that appears to be overdiagnosed, particularly in emergency departments. There are numerous instances of serious neurologic illness that were initially misdiagnosed as conversion disorder. Newer techniques of diagnostic imaging have helped to lower the rate of medical errors. In addition, functional MRI has identified specific areas of the brain that show differential activation in cases of conversion disorder, and imaging findings may eventually be useful in distinguishing conversion disorder.
Diagnostic issues
Diagnosis of conversion disorder is complicated by its coexistence with physical illness in as many as 60% of patients. Alternatively explained, a diagnosis of conversion disorder does not exclude the possibility of a concurrent organic disease. The examining doctor will usually order a mental health evaluation when conversion disorder is suspected, as well as x-rays, other imaging studies that may be useful, and appropriate laboratory tests. The doctor will also take a thorough patient history that will include the presence of recent stressors in the patient’s life, as well as a history of abuse. Children and adolescents are usually asked about their school experiences, one question they are asked is whether a recent change of school or an experience related to school may have intensified academic pressure.
In addition, there are a number of bedside tests that doctors can use to distinguish between symptoms of conversion disorder and symptoms caused by physical diseases. These may include the drop test, in which a “paralyzed” arm is dropped over the patient’s face. In conversion disorder, the arm will not strike the face. Other tests include applying a mildly painful stimulus to a “weak” or “numb” part of the body. The patient’s pulse rate will typically rise in cases of conversion disorder, and he or she will usually pull back the limb that is being touched.
Factors suggesting a diagnosis of conversion disorder
The doctor can also use a list of factors known to be associated with conversion disorder to assess the likelihood that a specific patient may have the disorder:
- age. Conversion disorder is rarely seen in children younger than six years or adults over 35 years.
- sex. The female:male ratio for the disorder ranges between 2:1 and 10:1. It is thought that higher rates of conversion disorder in women may reflect the greater vulnerability of females to abuse.
- residence. People who live in rural areas are more likely to develop conversion disorder than those who live in cities.
- level of education. Conversion disorder occurs less often among sophisticated or highly educated people.
- family history. Children sometimes develop conversion disorder from observing their parents’ reactions to stressors. This process is known as social modeling.
- a recent stressful change or event in the patient’s life.
An additional feature suggesting conversion disorder is the presence of la belle indiffe´rence. The French phrase refers to an attitude of relative unconcern on the patient’s part about the symptoms or their implications. La belle indiffe´rence is, however, much more common in adults with conversion disorder than in children or adolescents. Patients in these younger age groups are much more likely to react to their symptoms with fear or hopelessness. A recent review of the published reports of la belle indifférence found that this feature was not useful in discriminating conversion disorder from physically based disease because of muddy definitions and application of it in diagnosis.
Medical conditions that mimic conversion symptoms
It is important for the doctor to rule out serious medical disorders in patients who appear to have conversion symptoms. At least one study has found an approximately 4% rate of misdiagnosis of an actual physical problem as a conversion disorder. The following disorders must be considered in the differential diagnosis:
- multiple sclerosis (blindness resulting from optic neuritis)
- myasthenia gravis (muscle weakness)
- periodic paralysis (muscle weakness)
- myopathies (muscle weakness)
- polymyositis (muscle weakness)
- Guillain-Barrésyndrome (motor and sensory symptoms)
Treatments
Patients diagnosed with conversion disorder frequently benefit from a team approach to treatment and from a combination of treatment modalities. A team approach is particularly beneficial if the patient has a history of abuse, or if he or she is being treated for a concurrent physical condition or illness.
Medications
While there are no drugs for the direct treatment of conversion disorder, medications are sometimes given to patients to treat the anxiety or depression that may be associated with conversion disorder.
Psychotherapy
Psychodynamic psychotherapy is sometimes used with children and adolescents to help them gain insight into their symptoms. Cognitive-behavioral approaches have also been tried, with good results. Family therapy is often recommended for younger
KEY TERMS
Aphonia —Inability to speak caused by a functional disturbance of the voice box or vocal cords.
(la) Belle indifférence —A psychiatric symptom sometimes found in patients with conversion disorder, in which the patient shows a surprising lack of concern about the nature or implications of his/her physical symptom(s).
Conversion —In psychiatry, a process in which a repressed feeling, impulse, thought, or memory emerges in the form of a bodily symptom.
Diplopia —A disorder of vision in which a single object appears double. Diplopia is sometimes called double vision.
Dyskinesia —Difficulty in performing voluntary muscular movements.
Dystonia —A neurological disorder characterized by involuntary muscle spasms. The spasms can cause a painful twisting of the body and difficulty walking or moving.
Electroencephalogram (EEG) —A test that measures the electrical activity of the brain by means of electrodes placed on the scalp or in the brain itself.
Factitious disorder —A type of mental disturbance in which patients intentionally act physically or mentally ill without obvious benefits. It is distinguished from malingering by the absence of an obvious motive, and from conversion disorder by intentional production of symptoms.
Hysteria —In nineteenth-century psychiatric use, a neurotic disorder characterized by violent emotional outbursts and disturbances of the sensory and motor (movement-related) functions. The term “hysterical neurosis” is still used by some psychiatrists as a synonym for conversion disorder.
Malingering —Knowingly pretending to be physically or mentally ill to avoid some unpleasant duty or responsibility, or for economic benefit.
Myoclonus —An abrupt spasm or twitching in a muscle or group of muscles.
Narcotherapy —A form of psychotherapy that involves the administration of a drug that makes the patient drowsy.
Primary gain —In psychiatry, the principal psychological reason for the development of a patient’s symptoms. In conversion disorder, the primary gain from the symptom is the reduction of anxiety and the exclusion of an inner conflict from conscious awareness.
Pseudoseizure —A fit that resembles an epileptic seizure but is not associated with abnormal electrical discharges in the patient’s brain.
Psychogenic —Originating in the mind, or in a mental process or condition. The term “psychogenic” is sometimes used as a synonym for “conversion.”
Ptosis —Drooping of the upper eyelid.
Secondary gain —A term that refers to other benefits that a patient obtains from a conversion symptom. For example, a patient’s loss of function in an arm might require other family members to do the patient’s share of household chores; or they might give the patient more attention and sympathy than he or she usually receives.
Shaman —In certain indigenous tribes or groups, a person who acts as an intermediary between the natural and supernatural worlds. Shamans are regarded as having the power or ability to cure illnesses.
Social modeling —A process of learning behavioral and emotional-response patterns from observing one’s parents or other adults. Some researchers think that social modeling plays a part in the development of conversion disorder in children.
Somatoform disorders —A group of psychiatric disorders in the DSM-IV-TR classification that are characterized by external physical symptoms or complaints that are related to psychological problems rather than organic illness. Conversion disorder is classified as a somatoform disorder.
Stressor —A stimulus or event that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism.
patients whose symptoms may be related to family dysfunction. Group therapy appears to be particularly useful in helping adolescents to learn social skills and coping strategies, and to decrease their dependency on their families.
Inpatient treatment
Hospitalization is sometimes recommended for children with conversion disorders who are not helped by outpatient treatment. Inpatient treatment also allows for a more complete assessment of possible coexisting organic disorders, and for the child to improve his or her level of functioning outside of an abusive or otherwise dysfunctional home environment.
Alternative and complementary therapies
Alternative and complementary therapies that have been shown to be helpful in the treatment of conversion disorder include hypnosis, relaxation techniques, visualization, and biofeedback.
Prognosis
The prognosis for recovery from conversion disorder is highly favorable. Patients who have clearly identifiable stressors in their lives, acute onset of symptoms, and a short interval between symptom onset and treatment have the best prognosis. Of patients hospitalized for the disorder, over half recover within two weeks. Between 20% and 25% will relapse within a year. The individual symptoms of conversion disorder are usually self-limited and do not lead to lasting disabilities; however, patients with hysterical aphonia, paralysis, or visual disturbances, have better prognoses for full recovery than those with tremor or pseudoseizures.
Prevention
The incidence of conversion disorder in adults is likely to continue to decline with rising levels of formal education and the spread of basic information about human psychology. Prevention of conversion disorder in children and adolescents depends on better strategies for preventing abuse.
See alsoAbuse.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington D.C.: American Psychiatric Association, 2000.
“Conversion Disorder.” The Merck Manual of Diagnosis and Therapy, Mark H. Beers, MD and Robert Berkow, MD, eds. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Dorland’s Pocket Medical Dictionary, 25th ed. Philadelphia: W. B. Saunders Company, 1995.
Davenport, Noa, PhD, Ruth D. Schwartz, and Gail P. Elliott. Mobbing: Emotional Abuse in the American Workplace. Ames, IA: Civil Society Publishing, 1999.
Herman, Judith, MD. Trauma and Recovery, 2nd ed., revised. New York: Basic Books, 1997.
Pelletier, Kenneth R., MD. “Sound Mind, Sound Body: MindBody Medicine Comes of Age.” Chapter 2 in The Best Alternative Medicine. New York: Simon and Schuster, 2002.
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.
PERIODICALS
Al-Sharbati, M. M.,N.Viernes, A.Al-Hussaini, and others. “A Case of Bilaterial Ptosis with Unsteady Gait: Suggestibility and Culture in Conversion Disorder.” International Journal of Psychiatry in Medicine 31 (2001): 225–32.
Campo, John V. “Negative Reinforcement and Behavioral Management of Conversion Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 39 (June 2000): 787–90.
Crimlisk, Helen L., and others. “Slater Revisited: 6-Year Follow-Up of Patients with Medically Unexplained Motor Symptoms.” British Medical Journal 316 (Feb. 21, 1998): 582–86.
Glick, T. H., T. P. Workman, and S. V. Gaufberg. “Suspected Conversion Disorder: Foreseeable Risks and Avoidable Errors.” Academy of Emergency Medicine 7 (Nov. 2000): 1272–77.
Haghighi, S. S., and S. Meyer. “Psychogenic Paraplegia in a Patient with Normal Electrophysiologic Findings.” Spinal Cord 39 (Dec. 2001): 664–67.
Isaac, Mohan, and Chand, Prabhat K. “Dissociative and Conversion Disorders: Defining Boundaries.” Current Opinions in Psychiatry 19 (2006): 61–66.
Meyers, Timothy J., Bruce W. Jafek, and Arlen D. Meyers. “Recurrent Psychogenic Coma Following Tracheal Stenosis Repair.” Archives of Otolaryngology—Head & Neck Surgery 125 (Nov. 1999): 1267.
Moene, F. C., E. H. Landberg, K. A. Hoogduin, and others. “Organic Syndromes Diagnosed as Conversion Disorder: Identification and Frequency in a Study of 85 Patients.” Journal of Psychosomatic Research w49 (July 2000): 7–12.
Mori, S., S. Fujieda, T. Yamamoto, and others. “Psychogenic Hearing Loss with Panic Anxiety Attack After the Onset of Acute Inner Ear Disorder.” ORL Journal of Otorhinolaryngology and Related Specialties 64 (Jan.-Feb. 2002): 41–44.
Pineros, Marion, Diego Rosselli, Claudia Calderon. “An Epidemic of Collective Conversion and Dissociation Disorder in an Indigenous Group of Colombia: Its Relation to Cultural Change.” Social Science & Medicine 46 (June 1998): 1425–28.
Shalbani, Aziz, and Marwan N. Sabbagh. “Pseudoneuro-logic Syndromes: Recognition and Diagnoses.” American Family Physician 57 (May 15, 1998): 207–12.
Stone, Jon, and others. “Systematic Review of Misdiagnosis of Conversion Symptom and ‘Hysteria”’ British Medical Journal (2005).
Stone, Jon, Roger Smyth, Alan Carson, Charles Warlow, and Michael Sharpe. “La Belle Indifference in Conversion Symptoms and Hysteria.” British Journal of Psychiatry 188 (2006): 204–209.
Syed, E. U., and others. “Conversion Disorder: Difficulties in Diagnosis Using DSM-IV/ICD-10.” Journal of the Pakistani Medical Association 51 (April 2001): 143–45.
Wyllie, Elaine, John P. Glazer, Selim Benbadis, and others. “Psychiatric Features of Children and Adults with Pseudoseizures.” Archives of Pediatrics & Adolescent Medicine 153 (March 1999): 244–48.
Yasamy, M. T., A. Bahramnezhad, H. Ziaaddini. “Post-vaccination Mass Psychogenic Illness in an Iranian Rural School.” Eastern Mediterranean Health Journal 5 (July 1999): 710–16.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. Telephone: (202) 966-7300. Fax: (202) 966-2891. <http://www.aacap.org>.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <http://www.nimh.nih.gov>.
Rebecca J. Frey, PhD
Emily Jane Willingham, PhD
Conversion disorder
Conversion disorder
Definition
Conversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders , 4th Edition, Text Revision, also known as the DSM-IV-TR, as a mental disorder whose central feature is the appearance of symptoms affecting the patient's senses or voluntary movements that suggest a neurological or general medical disease or condition. Somatoform disorders are marked by persistent physical symptoms that cannot be fully explained by a medical condition, substance abuse, or other mental disorder, and seem to stem from psychological issues or conflicts. The DSM-IV-TR classifies conversion disorder as one of the somatoform disorders, first classified as a group of mental disorders by the DSM III in 1980. Other terms that are sometimes used for conversion disorder include pseudoneurologic syndrome, hysterical neurosis , and psychogenic disorder.
Conversion disorder is a major reason for visits to primary care practitioners. One study of health care utilization estimates that 25–72% of office visits to primary care doctors involve psychological distress that takes the form of somatic (physical) symptoms. Another study estimates that at least 10% of all medical treatments and diagnostic services are ordered for patients with no evidence of organic disease. Conversion disorder carries a high economic price tag. Patients who convert their emotional problems into physical symptoms spend nine times as much for health care as people who do not somatosize; and 82% of adults with conversion disorder stop working because of their symptoms. The annual bill for conversion disorder in the United States comes to $20 billion, not counting absenteeism from work and disability payments.
Description
Conversion disorder has a complicated history that helps to explain the number of different names for it. Two eminent neurologists of the nineteenth century, Jean-Martin Charcot in Paris and Josef Breuer in Vienna were investigating what was then called hysteria, a disorder primarily affecting women (the term "hysteria" comes from the Greek word for uterus or womb). Women diagnosed with hysteria had frequent emotional outbursts and a variety of neurologic symptoms, including paralysis, fainting spells, convulsions, and temporary loss of sight or hearing. Pierre Janet (one of Charcot's students), and Breuer independently came to the same conclusion about the cause of hysteria—that it resulted from psychological trauma. Janet, in fact, coined the term "dissociation" to describe the altered state of consciousness experienced by many patients who were diagnosed with hysteria.
The next stage in the study of conversion disorder was research into the causes of "combat neurosis" in World War I (1914-1918) and World War II (1939-1945). Many of the symptoms observed in "shell-shocked" soldiers were identical to those of "hysterical" women. Two of the techniques still used in the treatment of conversion disorder—hypnosis and narcotherapy—were introduced as therapies for combat veterans. The various terms used by successive editions of the DSM and the ICD (the European equivalent of DSM ) for conversion disorder reflect its association with hysteria and dissociation. The first edition of the DSM (1952) used the term "conversion reaction." DSM-II (1968) called the disorder "hysterical neurosis (conversion type)," DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) have all used the term "conversion disorder." ICD-10 refers to it as "dissociative (conversion) disorder."
DSM-IV-TR (2000) specifies six criteria for the diagnosis of conversion disorder. They are:
- The patient has one or more symptoms or deficits affecting the senses or voluntary movement that suggest a neurological or general medical disorder.
- The onset or worsening of the symptoms was preceded by conflicts or stressors in the patient's life.
- The symptom is not faked or produced intentionally.
- The symptom cannot be fully explained as the result of a general medical disorder, substance intake, or a behavior related to the patient's culture.
- The symptom is severe enough to interfere with the patient's schooling, employment, or social relationships, or is serious enough to require a medical evaluation.
- The symptom is not limited to pain or sexual dysfunction, does not occur only in the context of somatization disorder , and is not better accounted for by another mental disorder.
DSM-IV lists four subtypes of conversion disorder: conversion disorder with motor symptom or deficit; with sensory symptom or deficit; with seizures or convulsions; and with mixed presentation.
Although conversion disorder is most commonly found in individuals, it sometimes occurs in groups. One such instance occurred in 1997 in a group of three young men and six adolescent women of the Embera, an indigenous tribe in Colombia. The young people believed that they had been put under a spell or curse, and developed dissociative symptoms that were not helped by antipsychotic medications or traditional herbal remedies. They were cured when shamans from their ethnic group came to visit them. The episode was attributed to psychological stress resulting from rapid cultural change.
Another example of group conversion disorder occurred in Iran in 1992. Ten girls out of a classroom of 26 became unable to walk or move normally following tetanus inoculations. Although the local physicians were able to treat the girls successfully, public health programs to immunize people against tetanus suffered an immediate negative impact. One explanation of group conversion disorder is that an individual who is susceptible to the disorder is typically more affected by suggestion and easier to hypnotize than the average person.
Causes and symptoms
Causes
The immediate cause of conversion disorder is a stressful event or situation that leads the patient to develop bodily symptoms as symbolic expressions of a long-standing psychological conflict or problem. One psychiatrist has defined the symptoms as "a code that conceals the message from the sender as well as from the receiver."
Two terms that are used in connection with the causes of conversion disorder are primary gain and secondary gain. Primary gain refers to the lessening of the anxiety and communication of the unconscious wish that the patient derives from the symptom(s). Secondary gain refers to the interference with daily tasks, removal from the uncomfortable situation, or increased attention from significant others that the patient obtains as a result of the symptom(s).
Physical, emotional, or sexual abuse can be a contributing cause of conversion disorder in both adults and children. In a study of 34 children who developed pseudoseizures, 32% had a history of depression or sexual abuse, and 44% had recently experienced a parental divorce, death, or violent quarrel. In the adult population, conversion disorder may be associated with mobbing, a term that originated among European psychiatrists and industrial psychologists to describe psychological abuse in the workplace. One American woman who quit her job because of mobbing was unable to walk for several months. Adult males sometimes develop conversion disorder during military basic training. Conversion disorder may also develop in adults as a long-delayed after-effect of childhood abuse. A team of surgeons reported on the case of a patient who went into a psychogenic coma following a throat operation. The surgeons found that she had been repeatedly raped as a child by her father, who stifled her cries by smothering her with a pillow.
Symptoms
In general, symptoms of conversion disorder are not under the patient's conscious control, and are frequently mysterious and frightening to the patient. The symptoms usually have an acute onset, but sometimes worsen gradually.
The most frequent forms of conversion disorder in Western countries include:
- Pseudoparalysis. In pseudoparalysis, the patient loses the use of half of his/her body or of a single limb. The weakness does not follow anatomical patterns and is often inconsistent upon repeat examination.
- Pseudosensory syndromes. Patients with these syndromes often complain of numbness or lack of sensation in various parts of their bodies. The loss of sensation typically follows the patient's notion of their anatomy, rather than known characteristics of the human nervous system.
- Pseudoseizures. These are the most difficult symptoms of conversion disorder to distinguish from their organic equivalents. Between 5% and 35% of patients with pseudoseizures also have epilepsy. Electroencephalograms (EEGs) or measurement of serum prolactin levels, are useful in distinguishing pseudoseizures from epileptic seizures.
- Pseudocoma. Pseudocoma is also difficult to diagnose. Because true coma may indicate a life-threatening condition, patients must be given standard treatments for coma until the diagnosis can be established.
- Psychogenic movement disorders . These can mimic myoclonus, parkinsonism, dystonia, dyskinesia, and tremor. Doctors sometimes give patients with suspected psychogenic movement disorders a placebo medication to determine whether the movements are psychogenic or the result of an organic disorder.
- Pseudoblindness. Pseudoblindness is one of the most common forms of conversion disorder related to vision. Placing a mirror in front of the patient and tilting it from side to side can often be used to determine pseudoblindness, because humans tend to follow the reflection of their eyes.
- Pseudodiplopia. Pseudodiplopia, or seeing double, can usually be diagnosed by examining the patient's eyes.
- Pseudoptosis. Ptosis, or drooping of the upper eyelid, is a common symptom of myasthenia gravis and a few other disorders. Some people can cause their eyelids to droop voluntarily with practice. The diagnosis can be made on the basis of the eyebrow; in true ptosis, the eyebrows are lifted, whereas in pseudoptosis they are lowered.
- Hysterical aphonia. Aphonia refers to loss of the ability to produce sounds. In hysterical aphonia, the patient's cough and whisper are normal, and examination of the throat reveals normal movement of the vocal cords.
Psychiatrists working in various parts of the Middle East and Asia report that the symptoms of conversion disorder as listed by DSM-IV and ICD-10 do not fit well with the symptoms of the disorder most frequently encountered in their patient populations.
Demographics
The lifetime prevalence rates of conversion disorder in the general U.S. population are estimated to fall between 11 and 300 per 100,000 people. The differences in the estimates reflect differences in the method of diagnosis as well as some regional population differences. In terms of clinical populations, conversion disorder is diagnosed in 5%–14% of general hospital patients; 1%–3% of outpatient referrals to psychiatrists; and 5%–25% of psychiatric outpatients.
Among adults, women diagnosed with conversion disorder outnumber men by a 2:1 to 10:1 ratio; among children, however, the gender ratio is closer to 1:1. Less educated people and those of lower socioeconomic status are more likely to develop conversion disorder; race by itself does not appear to be a factor. There is, however, a major difference between the populations of developing and developed countries; in developing countries, the prevalence of conversion disorder may run as high as 31%.
Diagnosis
Conversion disorder is one of the few mental disorders that appears to be overdiagnosed, particularly in emergency departments. There are numerous instances of serious neurologic illness that were initially misdiagnosed as conversion disorder. Newer techniques of diagnostic imaging have helped to lower the rate of medical errors.
Diagnostic issues
Diagnosis of conversion disorder is complicated by its coexistence with physical illness in as many as 60% of patients. Alternatively explained, a diagnosis of conversion disorder does not exclude the possibility of a concurrent organic disease. The examining doctor will usually order a mental health evaluation when conversion disorder is suspected, as well as x rays, other imaging studies that may be useful, and appropriate laboratory tests. The doctor will also take a thorough patient history that will include the presence of recent stressors in the patient's life, as well as a history of abuse. Children and adolescents are usually asked about their school experiences; one question they are asked is whether a recent change of school or an experience related to school may have intensified academic pressure.
In addition, there are a number of bedside tests that doctors can use to distinguish between symptoms of conversion disorder and symptoms caused by physical diseases. These may include the drop test, in which a "paralyzed" arm is dropped over the patient's face. In conversion disorder, the arm will not strike the face. Other tests include applying a mildly painful stimulus to a "weak" or "numb" part of the body. The patient's pulse rate will typically rise in cases of conversion disorder, and he or she will usually pull back the limb that is being touched.
Factors suggesting a diagnosis of conversion disorder
The doctor can also use a list of factors known to be associated with conversion disorder to assess the likelihood that a specific patient may have the disorder:
- Age. Conversion disorder is rarely seen in children younger than six years or adults over 35 years.
- Sex. The female to male ratio for the disorder ranges between 2:1 and 10:1. It is thought that higher rates of conversion disorder in women may reflect the greater vulnerability of females to abuse.
- Residence. People who live in rural areas are more likely to develop conversion disorder than those who live in cities.
- Level of education. Conversion disorder occurs less often among sophisticated or highly educated people.
- Family history. Children sometimes develop conversion disorder from observing their parents' reactions to stressors. This process is known as social modeling .
- A recent stressful change or event in the patient's life.
An additional feature suggesting conversion disorder is the presence of la belle indifférence. The French phrase refers to an attitude of relative unconcern on the patient's part about the symptoms or their implications. La belle indifférence is, however, much more common in adults with conversion disorder than in children or adolescents. Patients in these younger age groups are much more likely to react to their symptoms with fear or hopelessness.
Medical conditions that mimic conversion symptoms
It is important for the doctor to rule out serious medical disorders in patients who appear to have conversion symptoms. The following disorders must be considered in the differential diagnosis:
- multiple sclerosis (blindness resulting from optic neuritis)
- myasthenia gravis (muscle weakness)
- periodic paralysis (muscle weakness)
- myopathies (muscle weakness)
- polymyositis (muscle weakness)
- Guillain-Barré syndrome (motor and sensory symptoms)
Treatments
Patients diagnosed with conversion disorder frequently benefit from a team approach to treatment and from a combination of treatment modalities. A team approach is particularly beneficial if the patient has a history of abuse, or if he or she is being treated for a concurrent physical condition or illness.
Medications
While there are no drugs for the direct treatment of conversion disorder, medications are sometimes given to patients to treat the anxiety or depression that may be associated with conversion disorder.
Psychotherapy
Psychodynamic psychotherapy is sometimes used with children and adolescents to help them gain insight into their symptoms. Cognitive behavioral approaches have also been tried, with good results. Family therapy is often recommended for younger patients whose symptoms may be related to family dysfunction. Group therapy appears to be particularly useful in helping adolescents to learn social skills and coping strategies, and to decrease their dependency on their families.
Inpatient treatment
Hospitalization is sometimes recommended for children with conversion disorders who are not helped by outpatient treatment. Inpatient treatment also allows for a more complete assessment of possible coexisting organic disorders, and for the child to improve his or her level of functioning outside of an abusive or otherwise dysfunctional home environment.
Alternative and complementary therapies
Alternative and complementary therapies that have been shown to be helpful in the treatment of conversion disorder include hypnosis, relaxation techniques, visualization, and biofeedback .
Prognosis
The prognosis for recovery from conversion disorder is highly favorable. Patients who have clearly identifiable stressors in their lives, acute onset of symptoms, and a short interval between symptom onset and treatment, have the best prognosis. Of patients hospitalized for the disorder, over half recover within two weeks. Between 20% and 25% will relapse within a year. The individual symptoms of conversion disorder are usually self-limited and do not lead to lasting disabilities; however, patients with hysterical aphonia, paralysis, or visual disturbances, have better prognoses for full recovery than those with tremor or pseudoseizures.
Prevention
The incidence of conversion disorder in adults is likely to continue to decline with rising levels of formal education and the spread of basic information about human psychology. Prevention of conversion disorder in children and adolescents depends on better strategies for preventing abuse.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.
"Conversion Disorder." Section 15, Chapter 186 inThe Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Davenport, Noa, PhD, Ruth D. Schwartz, and Gail P. Elliott. Mobbing: Emotional Abuse in the American Workplace. Ames, IA: Civil Society Publishing, 1999.
Dorland's Pocket Medical Dictionary. 25th edition. Philadelphia: W. B. Saunders Company, 1995.
Herman, Judith, MD. Trauma and Recovery. 2nd edition, revised. New York: Basic Books, 1997.
Pelletier, Kenneth R., MD. "Sound Mind, Sound Body: MindBody Medicine Comes of Age." Chapter 2 in The Best Alternative Medicine. New York: Simon and Schuster, 2002.
World Health Organization (WHO). The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992.
PERIODICALS
Al-Sharbati, M. M., N. Viernes, A. Al-Hussaini, and others. "A Case of Bilaterial Ptosis with Unsteady Gait: Suggestibility and Culture in Conversion Disorder." International Journal of Psychiatry in Medicine 31 (2001): 225-232.
Campo, John V. "Negative Reinforcement and Behavioral Management of Conversion Disorder." Journal of the American Academy of Child and Adolescent Psychiatry 39 (June 2000): 787-790.
Crimlisk, Helen L., and others. "Slater Revisited: 6-Year Follow-Up of Patients with Medically Unexplained Motor Symptoms." British Medical Journal 316 (February 21, 1998): 582-586.
Glick, T. H., T. P. Workman, S. V. Gaufberg. "Suspected Conversion Disorder: Foreseeable Risks and Avoidable Errors." Academy of Emergency Medicine 7 (November 2000): 1272-1277.
Haghighi, S. S., and S. Meyer. "Psychogenic Paraplegia in a Patient with Normal Electrophysiologic Findings." Spinal Cord 39 (December 2001): 664-667.
Langmann, A., S. Lindner, N. Kriechbaum. "Functional Reduction of Vision Symptomatic of a Conversion Reaction in a Paediatric Population. [in German]" Klinische Monatsblatter Augenheilkunde 218 (October 2001): 677-681.
Meyers, Timothy J., Bruce W. Jafek, Arlen D. Meyers. "Recurrent Psychogenic Coma Following Tracheal Stenosis Repair." Archives of Otolaryngology—Head & Neck Surgery 125 (November 1999): 1267.
Moene, F. C., E. H. Landberg, K. A. Hoogduin, and others. "Organic Syndromes Diagnosed as Conversion Disorder: Identification and Frequency in a Study of 85 Patients." Journal of Psychosomatic Research 49 (July 2000): 7-12.
Mori, S., S. Fujieda, T. Yamamoto, and others. "Psychogenic Hearing Loss with Panic Anxiety Attack After the Onset of Acute Inner Ear Disorder." ORL Journal of Otorhinolaryngology and Related Specialties 64 (January-February 2002): 41-44.
Pineros, Marion, Diego Rosselli, Claudia Calderon. "An Epidemic of Collective Conversion and Dissociation Disorder in an Indigenous Group of Colombia: Its Relation to Cultural Change." Social Science & Medicine 46 (June 1998): 1425-1428.
Shalbani, Aziz, and Marwan N. Sabbagh. "Pseudoneurologic Syndromes: Recognition and Diagnoses." American Family Physician 57 (May 15, 1998): 207-212.
Soares, Neelkamal, and Linda Grossman. "Somatoform Disorder: Conversion." eMedicine Journal 2 (September 14, 2001).
Syed, E. U., and others. "Conversion Disorder: Difficulties in Diagnosis Using DSM-IV/ICD-10." Journal of the Pakistani Medical Association 51 (April 2001): 143-145.
Wyllie, Elaine, John P. Glazer, Selim Benbadis, and others. "Psychiatric Features of Children and Adults with Pseudoseizures." Archives of Pediatrics & Adolescent Medicine 153 (March 1999): 244-248.
Yasamy, M. T., A. Bahramnezhad, H. Ziaaddini. "Post-vaccination Mass Psychogenic Illness in an Iranian Rural School." Eastern Mediterranean Health Journal 5 (July 1999): 710-716.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007.(202) 966-7300. Fax: (202) 966-2891. <www.aacap.org>.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov>.
Rebecca J. Frey, Ph.D
Conversion Disorder
Conversion Disorder
What Causes Conversion Disorder?
What Are the Symptoms of Conversion Disorder?
How Is Conversion Disorder Diagnosed and Treated?
Conversion disorder is a psychological condition in which a person loses abilities such as seeing, hearing, or speaking or becomes paralyzed, but no medical explanation can be found to explain the symptoms. Symptoms of conversion disorder often begin after some stressful experience, and they have traditionally been thought of as an expression of emotional conflict or need.
KEYWORDS
for searching the Internet and other reference sources
Factitious disorder
Hysteria
Malingering
Stress
What Is Conversion Disorder?
Conversion disorder is a mental disorder in which psychological symptoms are converted to physical symptoms, such as blindness, paralysis, or seizures. Unlike malingering, in which a person fakes an illness or injury, a person with conversion disorder does not intentionally produce symptoms.
Conversion disorder is rare, occurring in only about 1 to 3 out of 10,000 people. It is even less common in children younger than 10 years of age. Conversion disorder can be triggered by extreme psychological stress, such as injury, death of a loved one, or a dangerous situation. For example, in wartime, some soldiers undergoing heavy bombardment but not wounded were hospitalized because they could not walk or speak after the battle. Conversion disorder under these circumstances has been called shell shock and battle fatigue. In other circumstances, the purpose of conversion disorder appears to be to help the individual avoid or escape from a highly stressful situation.
What Causes Conversion Disorder?
The old term for conversion disorder was hysteria. Physicians in ancient Greece believed that hysteria only occurred in females and that it was caused by the uterus* wandering in the body (the Greek word for uterus is hystera). For centuries thereafter, people with hysteria were regarded as fakers or as imagining their symptoms. In the seventeenth century, some people with hysteria were thought to be involved with witchcraft and were burned at the stake.
- * uterus
- (YOO-ter-us) in humans is the organ in females in which a fetus develops and grows during pregnancy.
The term conversion disorder came into use only in the late twentieth century. It is derived from the early work of the Austrian physician Sigmund Freud, the founder of psychoanalysis*. Freud believed that in times of extreme emotional stress, painful feelings or conflicts are repressed (kept from awareness or consciousness) and are converted into physical symptoms to relieve anxiety. Even in the twenty-first century, mental health experts do not all agree on the precise psychological mechanisms underlying conversion disorder. However, many mental health professionals see the benefits associated with the symptoms of conversion disorder, such as sympathy, care, and the avoidance of stressful situations, as significant to the disorder.
- * psychoanalysis
- (sy-ko-a-NALi-sis) is a method of treating a person with psychological problems, based on the theories of Dr. Sigmund Freud. It involves sessions in which a therapist encourages a person to talk freely about personal experiences, and the psychoanalyst interprets the patient’s ideas and dreams.
What Are the Symptoms of Conversion Disorder?
Sometimes people with conversion disorder have tremors or symptoms that resemble fainting spells or seizures*. There also may be loss of feeling in various parts of the body, or loss of the sense of smell, and symptoms may occur together. For instance, following an automobile accident a person may be unable to move or feel sensation in an arm or leg, even though no injury to the limb is apparent. Other people may have difficulty swallowing or feel like they have a lump in their throat. Interestingly, some people with conversion disorder may seem quite comfortable with their symptoms, even though they may be greatly handicapped by them.
- * seizures
- (SEE-zhurz) can occur when the electrical patterns of the brain are interrupted by powerful, rapid bursts of electrical energy, which may cause a person to fall down, make jerky movements, or stare blankly into space.
How Is Conversion Disorder Diagnosed and Treated?
Possible medical, or physical, causes of a patient’s symptoms need to be ruled out to establish the diagnosis of conversion disorder. Special instruments that measure electrical activity in the muscles and the brain can rule out some physical disorders. In addition, experienced physicians using close observation can often discover important diagnostic clues. For example, without realizing it a patient may momentarily use an arm or a leg that is supposed to be paralyzed. This clue would indicate that the symptom is psychological rather than physical, and might indicate conversion disorder. To rule out that the patient is just pretending to be ill, a mental health professional would need to perform a clinical interview to learn about the history of the individual and family, stressors that may be present, benefits the patient derives from the symptoms, and what factors may be sustaining the symptoms.
Conversion disorder is typically treated with psychotherapy*. The therapist attempts to help the patient understand whatever unconscious emotional conflicts or needs or gains may have given rise to the symptoms. In some instances, symptoms of the disorder may last for years. With treatment, however, the symptoms of conversion disorder frequently last for only brief periods.
- * psychotherapy
- (sy-ko-THER-apea) is the treatment of mental and behavioral disorders by support and insight to encourage healthy behavior patterns and personality growth.
See also
Hypochondria
Malingering
Munchausen Syndrome
Stress