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The Neuropsychiatry of Conversion Disorder
Selma Aybek; Richard A. Kanaan; Anthony S. David
Curr Opin Psychiatry. 20082!"#$:275%280. &2008 'ippincott (illiams ) (il*ins
Posted 05/08/2008
Abstract and Introduction
Abstract
Purpose of Review: +urin, the past two decades there has -een a relative sur,e o. interest in
conversion disorder/ and a multitude o. studies have emer,ed on the su-0ect. (ith continuin,
developments in neuroscience 1 mainly -rain ima,in, 1 new applications to conversion disorder are
-ein, reported every year.
Recent indin!s: +ia,nosis continues to represent a challen,e/ althou,h neurolo,ical si,ns are
increasin,ly -ein, developed and validated to assist with this. Psychiatric co%mor-idity dia,nosed
accordin, to operational criteria is common. 2rain ima,in, studies have -rou,ht some clues to
understandin, the pathophysiolo,y o. conversion disorder.
Summary: 3vidence%-ased medicine re4uires relia-le dia,nostic criteria/ and attempts have recently
-een made to validate some o. the well *nown neurolo,ical si,ns o. conversion disorder. 5rom a
psychiatric point o. view/ there is a need .or ,reater understandin, o. the aetiolo,y and mechanisms
underlyin, conversion disorder and its relationship to other psychiatric disorders. 6lthou,h advances have
-een made -oth in dia,nostic methods and in the ,roundwor* .or a neuro-iolo,ical model/ no clear
rationale .or treatment is yet availa-le and .urther research is stron,ly needed.
Introduction
7ince its pea* at the turn o. the 20th century/ there has -een a steady decline in the medical community8s
interest in conversion disorder to a point that the disease itsel. was thou,ht to have waned.
9!:
;n the past
decade/ however/ such interest has under,one a revival. ;t has -een esta-lished that conversion disorder
remains common/ and disa-lin,/
92:
while advances in neuroscience have ,iven hope .or new insi,ht into
its -iolo,ical mechanisms. <here have -een several studies aimed at re.inin, the dia,nosis and
understandin, the pathophysiolo,y/ which we shall review here.
A Problematic Dia!nosis
Conversion disorder is a psychiatric dia,nosis -ut rarely presents to psychiatrists. <he presentin,
complaint is typically o. =one or more symptoms or de.icits a..ectin, voluntary motor or sensory .unction>
9criterion 6 in the +ia,nostic and 7tatistical ?anual o. ?ental +isorder "+7?$%;@: and there.ore usually
presents to a neurolo,ist/ where it represents a dia,nostic challen,e. <he .ull dia,nosis/ however/
re4uires an =associated psycholo,ical .actor> "criterion 2$ and most neurolo,ists do not .eel com.orta-le
ma*in, such an association/ since they usually do not eAplore the psycholo,ical aspects in su..icient
depth in their evaluation. <heir preliminary dia,nosis o. =medically uneAplained symptoms> may lead
patients either to view their doctor to -e incompetent or to view their disease as a rare condition that
needs .urther investi,ation.
<he .ull dia,nosis usually re4uires two specialists/ -oth a psychiatrist and a neurolo,ist/ and there.ore
needs ,ood colla-oration -etween them in the multiple%step process: care.ul history ta*in, and physical
1
eAamination -y the neurolo,ist/ re.erral to the psychiatrist/ and .inally/ optimally/ a clear 0oint eAplanation
to the patient. <his colla-oration is sometimes 0eopardiBed -y the .ear o. misdia,nosis the psychiatrist
has to trust the neurolo,ist that or,anic disorders eAplainin, the symptoms have -een entirely eAcluded. ;t
was previously understood that conversion disorder o.ten represented missed or,anic conditions and
that/ at .ollow up/ such a disorder would -e .ound in up to one%third o. patients.
9#:
6 thorou,h meta%
analysis/
94:
however/ recently esta-lished that misdia,nosis rates are around 4C in conversion disorder 1
no more .re4uent than in diseases such as schiBophrenia or motor neurone disease.
6nother di..iculty in esta-lishin, a dia,nosis o. conversion disorder lies in the lac* o. consensus
concernin, the psycholo,ical mechanism o. criterion 2. <his is illustrated -y the di..erent classi.ication
cate,ories in +7?%;@ and ;nternational Classi.ication o. +isease%!0. ;n the .ormer/ conversion disorder is
,rouped with the somato.orm disorders and has -een classi.ied as such mainly -ecause o. the presence
o. a symptom mimic*in, a medical disorder/ -ut also -ecause the mechanism thou,ht to -e involved is a
=sym-olic resolution o. an unconscious psycholo,ical con.lict>/ =convertin,> the stressor into a physical
symptom. ;n the latter/ conversion disorder is included with the dissociative disorders/ implyin, that the
production o. the symptoms is the result o. =a complete or partial loss o. the normal inte,ration -etween
memories o. the past/ awareness o. identity and immediate sensations and control o. -odily movement>. ;t
also implies that a satis.actory psycholo,ical eAplanation can -e ,iven .or the symptom/ when .indin, an
associated psycholo,ical .actor/ even i. denied -y the individual. <he de-ate concernin, which de.inition
is more ade4uate is still active/
95D:
and will pro-a-ly ,o on until 20!!/ when the new +7?%@ and
;nternational Classi.ication o. +isease%!! classi.ications are due.
"he #eurolo!ical Dia!nosis
<he neurolo,ical presentation o. conversion disorder has -een descri-ed .or centuries -ut/ with the
development o. evidence%-ased medicine and more sophisticated investi,ations/ there have -een
attempts to esta-lish the neurolo,ical part o. the dia,nosis on more than a clinical picture and the overall
impression o. the physician. 7ome attempts to validate clinical si,ns are descri-ed -elow.
5or motor symptoms/ the dia,nosis relies on si,ns such as inconsistency "e.,. the patient displays a le,
monople,ia when tested on the -ed eAamination/ -ut is then a-le to stand on one .oot to put his trousers
-ac* on$ and ,ive%way wea*ness. 6lthou,h widely *nown and used -y the eAperienced neurolo,ist/ these
si,ns may not relia-ly eAclude neurolo,ical disease. ;n a study on #0 patients admitted .or or,anic
neurolo,ical disease/
9E:
seven alle,ed .eatures o. conversion disorder have -een tested/ includin, ,ive%
way wea*ness/ which was .ound in #0C o. cases. <he Foover8s si,n "involuntary eAtension o. a pseudo%
paralysed le, when the =,ood le,> is .leAin, a,ainst resistance$ is a ,ood test o. motor conversion
disorder/ which was not eAamined in the Gould study. 6 4uantitative evaluation o. the Foover8s si,n with
computeriBed myometry has shown a si,ni.icant di..erence -etween or,anic paralysis and pseudo%
paralysis/
97:
althou,h its relia-ility has not -een validated in its 4ualitative .orm/ as used in the clinic
settin,.
<he dia,nosis o. psycho,enic movement disorders relies mostly on the o-servation -y an eAperienced
movement disorder specialist/ and 5ahn and (illiams
98:
developed clinical dia,nostic criteria .or
psycho,enic dystonia that were then eAtended to all psycho,enic movement disorders. <hose criteria
have -een recently modi.ied and their validity esta-lished.
9H:
+espite some methodolo,ical wea*nesses
remainin, "such as the retrospective desi,n$/ their preliminary results showed ,ood speci.icity "HEC$ and
sensitivity "H7C$. Psycho,enic tremor has recently -een the su-0ect o. a separate validation.
9!0:
;ts
dia,nosis rests on the presence o. varia-ility in .re4uency and amplitude/ distracti-ility and entrainment.
<he clinical relevance o. those si,ns was assessed -y means o. -linded ratin,s o. video recordin, o. !2
patients with psycho,enic tremor and ## patients with essential tremor. <he .indin, o. distracti-ility "-y
contralateral alternate .in,er tappin,$ -rou,ht a speci.icity o. 72.7C and a speci.icity o. 7#.#C.
7urprisin,ly/ entrainment did not help to di..erentiate psycho,enic tremor .rom essential tremor/ and
neither did su,,esti-ility "-y hyperventilation and/or tunin, .or*$.
2
<here are no ,ood validated clinical si,ns to distin,uish sensory loss o. psycho,enic or or,anic ori,in and
the clinician usually relies on discrepancies "e.,. a patient with complete le, anaesthesia and a-sent
proprioception should not demonstrate a normal Iom-er, si,n/ and one would eApect some cutaneous
lesions/ li*e in a patient with dia-etes$ or nonor,anic distri-ution "a hemi%le, territory/ .or eAample/ not
correspondin, to any radicular/ truncal or central distri-ution$.
='a -elle indi..erence> was a term used -y 5reud to re.er to the apparent indi..erence and cheer.ulness he
o-served in one o. his patients with hysteria/ and has since -een accepted as a clinical si,n su,,estin,
conversion disorder. 6 recent systematic study
9!!D:
eAamined the validity o. =la -elle indi..erence>/ reviewin,
!! studies pu-lished -etween !HE5 and 200E. <he median .re4uency o. =la -elle indi..erence> in #5E
pooled patients with conversion disorder was 2!C "ran,e 015C$ and in !57 patients with or,anic disease
was 2HC "ran,e 01E0C$. 6mon, the only .our controlled studies availa-le/ one demonstrated a
si,ni.icant association with hysteria/ whereas the three others .ound no di..erence -etween ,roups.
2e.ore drawin, a conclusion that this si,n is not use.ul in conversion disorder/ it must -e outlined that
important methodolo,ical issues were noted with no -linded study desi,n and only two ,ave a description
o. what they meant -y =la -elle indi..erence>. <his si,n currently has no clear de.inition and should not -e
used to di..erentiate or,anic .rom .unctional symptoms without .urther study.
Psycho,enic ,ait disorders can -e reco,niBed -y speci.ic patterns such as =wal*in, on ice> or
noneconomic postures "eccentric placement o. the centre o. ,ravity/ which puts eAtra demands on
-alance and stren,th systems/ li*e wal*in, with *nees .leAed$/ -ut no de.inite si,ns have -een .ormally
tested. 6 recent article
9!2:
mentions a potential new si,n that would -ene.it .rom .urther assessment: the
=chair si,n>/ where patients with psycho,enic ,ait disorder could propel a chair when sittin, on it -etter
than control individuals with or,anic ,ait disorders.
<he .indin, o. closed eyes durin, a seiBure -rin,s a positive predictive value o. 0.H4 "sensitivity HEC and
speci.icity H8C$ .or psycho,enic nonepileptic seiBures "PJ37s$.
9!#DD:
Other clinical si,ns/ althou,h not
validated/ are considered stron, indicators o. PJ37s: pelvic thrustin,/ opisthotonic archin,/ side%to%side
head sha*in,/ asynchronous movements/ stutterin,/ weepin,/ ,radual onset and termination. (hen
PJ37s are suspected/ the use o. 24%h video electroencephalo,ram monitorin,
9!4:
is the most accurate
test/ with an up to 7#C success rate in o-tainin, a dia,nosis.
9!5:
;. the pretest suspicion is hi,h/ -ased on
the presence o. the a.orementioned si,ns/ a short%term video electroencephalo,ram with induction "either
saline in0ection/ hyperventilation or photic drive$ can also have a hi,h yield "EEC$.
9!E:
PJ37 is one o. the
.ew conversion disorder syndromes .or which the dia,nosis is aided -y a simple -lood test: serum
prolactin measurement !0120 min a.ter the event. <he 6merican 6cademy o. Jeurolo,y
9!7:
has revealed
level 2 evidence .or this test to di..erentiate PJ37 .rom ,eneraliBed or compleA seiBures "E0C and 4EC
sensitivity/ respectively/ and HEC speci.icity .or -oth$. <he test/ however/ does not di..erentiate PJ37 .rom
syncopes/ as all or,anic =loss o. consciousness> mi,ht produce prolactin. <he presence o. stertorous
-reathin, has recently -een demonstrated
9!8/!HD:
as very use.ul in distin,uishin, seiBures .rom PJ37/ when
reported -y the medical sta...
(hile reportin, statistically validated si,ns/ we cannot resist mentionin, the <eddy -ear si,n: the
presence o. a stu..ed animal -rou,ht -y the patient to the electroencephalo,ram%monitorin, unit was
studied in H0# patients/
920:
and yielded a positive predictive value .or PJ37 o. 87C/ with a hi,h speci.icity
"H#C$ -ut low sensitivity "5.2C$.
3ven thou,h such o-0ective si,ns can help the clinician in reachin, a dia,nosis/ 0ust as all other medical
conditions/ it is the ,eneral clinical picture/ the eAperience o. the clinician and an acceptance that they will
ma*e mista*es .rom time to time that lead to the lowest rate o. misdia,nosis possi-le.
"he Psychiatric Dia!nosis
5rom a psychiatric point o. view/ it has -een shown that patients with conversion disorder o.ten have
associated mental illnesses/ mostly depression and anAiety disorders. 5in* et al.
92!:
reported 2#C o.
3
patients with conversion disorder had associated pho-ia/ anAiety or panic attac*s/ and 7ar et al.
922:

reported 50C anAiety/ 42C pho-ia/ #4C o-sessive1compulsive disorder/ !0C panic attac*s/ 7!C
a..ective disorder and #4C depression amon, patients with conversion disorder. ;n patients with
psycho,enic none%pileptic seiBures/
92#/24:
researchers .ound 47157C had associated depression/ #H147C
anAiety/ #514HC posttraumatic disorder/ E2C personality disorder/ and no psychotic disorders. Fence
multiple psychiatric co%mor-idities are common.
7ince the 5reudian model emphasiBed trauma and seAual a-use/ several studies have eAamined the
association o. history o. a-use with conversion disorder/ and .ound -etween 28C and 44C o. patients
reported a history o. physical a-use and 2412EC reported seAual a-use.
922/25:
;n a controlled study o. #0
patients with motor conversion disorder/
92E:
however/ only #C o. patients reported childhood a-use/ which
was not si,ni.icantly di..erent .rom control individuals. ;t may -e that a-use is more .re4uent in PJ37 than
in other clinical presentations o. conversion disorder/
927:
with up to E7C o. those patients reportin, past
physical or seAual a-use.
924:
<raumatic li.e events were associated with conversion disorder even -e.ore 5reud -ut a precise
4uanti.ication o. such an association is lac*in,/ mostly -ecause the study o. li.e events and trauma is
complicated -y the unrelia-ility o. sel.%report. ;n the conversion model/ a patient with conversion disorder
represses the traumatic event/ and there.ore would not consider the event relevant when as*ed to report
it/ and may not even =remem-er> it. 6 controlled study o. 50 patients
928:
did not .ind an increased num-er o.
stress.ul li.e events in patients with conversion disorder compared with patients with a..ective disorder -ut
did demonstrate a correlation -etween the reported unpleasantness o. events and the severity o. the
symptom. <he methodolo,y o. the study was not ideal/ with the events in 4uestion -ein, -ased on a sel.%
report 4uestionnaire. 6nother controlled study on #0 consecutive patients
92H:
did show a si,ni.icantly hi,her
num-er o. li.e events in the precedin, year o. the symptom onset in the conversion disorder ,roup. ;n this
study/ the -ias o. the sel.%report mi,ht have -een minimiBed -y the desi,n o. a semi%structured interview
aimed at eAplorin, .ive domains o. li.e events. ;t has also -een ar,ued that li.e events should -e
independent o. the illness. 5or eAample/ si,ni.icant harm to her child would -e considered a stress.ul li.e
event to a mother and mi,ht -e thou,ht responsi-le .or her symptoms however/ the .act that the mother
already had some mild symptoms at the time mi,ht lead to her ne,lectin, the child/ and thus the li.e event
may -e a conse4uence o. the disease and not an independent cause. <he 'i.e 3vent and +i..iculties
7chedule
9#0:
puts ,reat emphasis on independence in order to avoid the pro-lems o. reverse causality/
-ias and con.oundin,/ and would -e an important advance in eAplorin, the stressors .or patients with
conversion disorder.
9#!:
#eurobiolo!ical $orrelates
Conversion disorder presents with neurolo,ical symptoms and si,ns that are uneAplained -y neurolo,ical
disease. Fow then are the symptoms and si,ns produced/ i. they are not .ei,nedK ;n the !HE0s/
electrophysiolo,ical studies su,,ested a central cortico.u,al inhi-ition o. a..erent stimuli as responsi-le
.or hysterical sensory loss/ since evo*ed potentials showed a-normalities that disappeared when tested
a,ain a.ter resolution o. the symptoms8/
9#2:
with similar results replicated in two patients in 2004.
9##:
;n the
!HH0s/ .urther evidence o. central inhi-ition came .rom a sin,le%photon emission computed tomo,raphy
9#4:

study in a woman with sensorimotor hemisyndrome/ which demonstrated hypoper.usion in the
contralateral parietal re,ion and increased per.usion in the .rontal re,ion. <his pattern was supported -y a
positron emission tomo,raphy study o. a patient with hemiparesis/
9#5:
where a,ain increased activity was
.ound in the .rontal re,ion with activation o. the anterior cin,ulate and or-ito.rontal corteA. <he authors
hypothesiBed that .rontal re,ions were inhi-itin, the motor and premotor areas when the patient tried to
move the a..ected lim-. ;n 200!/ @uilleumier and collea,ues
9#E:
per.ormed a lar,er sample sin,le%photon
emission computed tomo,raphy study on seven patients with sensorimotor conversion disorder/ when
they were symptomatic and when a su-set o. them recovered. Ieduced -lood .low in the su-cortical
structures "contra%lateral thalamus/ putamen and caudate$ was .ound when a vi-ration stimulus "which
normally activates -oth sensory and motor cortices$ was applied to the a..ected lim-. <he pattern
normaliBed in those patients who su-se4uently recovered. <his study shed .urther li,ht on central inhi-itor
mechanisms/ involvin, not only cortical areas -ut also corticosu-cortical circuits.
4
<he central inhi-ition hypothesis does not address the 4uestion as to whether this inhi-ition is =voluntary>
or =involuntary>. 6 .ew studies have tried to distin,uish the two/ -y comparin, conversion disorder patients
with .ei,ners. 7pence and collea,ues
9#7:
demonstrated a hypoactivation o. the le.t dorsolateral pre.rontal
corteA durin, a motor tas* in three patients with conversion disorder irrespective o. the lateraliBation o.
the symptoms "two patients with le.t%sided paresis/ one with ri,ht%sided paresis$/ which was .ound neither
in .ei,ners nor in control individuals/ implicatin, the le.t dorsolateral pre%.rontal corteA in altered volition in
conversion disorder. 6nother study
9#8:
compared individuals hypnotiBed to have a su-0ectively real
paralysis with individuals .ei,nin, paralysis. <he .ormer demonstrated a contralateral activation o. the
or-ito.rontal re,ion and cere-ellum and an ipsilateral activation o. the thalamus and putamen. ?ore
recently/ a .unctional ma,netic resonance ima,in, study
9#H:
in .our patients with motor symptoms/
compared with .our control individuals .ei,nin, a motor de.icit/ implicated a networ* includin, the putamen
and the lin,ual ,yri -ilaterally/ the le.t in.erior .rontal ,yrus/ le.t insula and ri,ht middle .rontal and
or-ito.rontal cortices underlyin, conversion disorder.
Overall/ these ima,in, studies su,,est that compleA -rain mechanisms are involved in preventin, normal
cortical activity however/ no consistent model has yet emer,ed. ;n part/ this is -ecause o. the small
samples included and the hetero,eneity o. the symptoms eAamined.
6part .rom .unctional ima,in,/ studies o. patients with cere-ral lesions have implicated -rain dys.unction
in the symptoms o. conversion disorder. 5or eAample/ 3ames
940:
reported that a lar,e num-er o. patients
"#2C$ with hypoAia "and thus -asal ,an,lia lesions$ displayed conversion disorder symptoms. +ra*e
94!:

reported .ive cases o. hysteria in patients with le.t cere-ral hemisphere lesions.
6 structural neuroima,in, study
942:
su,,ested there may -e macroscopic a-normalities in the -rains o.
patients with conversion disorder a.ter all/ at least at the ,roup level. <he study .ound a si,ni.icant
reduction in the volume o. the -asal ,an,lia in !0 patients with conversion disorder/ compared with
control individuals/ althou,h no correlations with laterality or clinical varia-les were presented.
reudian %odel
3ven thou,h/ as discussed a-ove/ no de.inite pathophysiolo,ical model can eAplain conversion disorder/
there is ,ood evidence that neural circuits are involved in this patholo,y. 7hould we then conclude that
hysteria is a neurolo,ical disease a.ter allK Fence/ is the =associated psycholo,ical .actor> a coincidence
or even a conse4uence o. that particular -rain diseaseK (hat a-out the 5reudian model o. emotion
=converted> into somatic symptomsK
6 recent study
94#D:
demonstrated that ne,ative emotion "recall o. a traumatic event$ was lin*ed to
conversion disorder symptoms. (hen eAamined in a .unctional ma,netic resonance ima,in, scanner/ a
woman with a ri,ht hemiparesis showed increased activity in her ri,ht medial temporal lo-e "includin, the
amy,dala/ involved in emotional recall$ and concurrent deactivation o. her contralateral "le.t$ primary
motor corteA when cued to remem-er a *ey traumatic event lin*ed to the onset o. her symptoms. 5urther
studies on lar,er samples mi,ht help us understand the lin* -etween psycholo,ical stressors and the
development o. conversion disorder usin, a co,nitive model o. memory suppression.
"herapeutic Approach
<o -uild a rationale .or treatment/ a theoretical aetiolo,y is re4uired. Ln.ortunately/ even thou,h there are
promisin, clues/ as descri-ed a-ove/ no model/ and no treatment/ has -een clearly esta-lished. 6 recent
Cochrane review
944:
loo*ed at the availa-le treatments .or PJ37 and .ound only three relevant studies/ two
on hypnosis and one on paradoAical therapy/ which were insu..icient to draw any .irm conclusion. <here
also have -een claims made .or repetitive transcranial ma,netic stimulation/
945:
physiotherapy/
94E:
anti%
depressants/
947:
co,nitive -ehavioural therapy/
948:
paradoAical in0unction
94H:
".avourin, situations/ durin,
therapy sessions/ in which patients mi,ht a,,ravate their symptoms/ such as thin*in, o. a traumatic
5
event$ and a strate,ic -ehavioural approach
950:
"patients are assured that .ull recovery a.ter an inpatient
physiotherapy pro,ramme would -e the proo. o. an or,anic disease whereas no improvement would
imply a psychiatric cause .or the symptom$. 6 recent review
95!D:
o. #4 availa-le randomiBed control trials o.
treatments in somato.orm disorders "with only three speci.ic to conversion disorder$ showed some
evidence .or co,nitive -ehavioural therapy with no evidence o. a positive e..ect o. antidepressant
medication.
$onclusion
Over the past !0 years there has -een a resur,ence in research into conversion disorder. <his research/
mostly utiliBin, -rain ima,in,/ has ,iven some clues to the compleA mechanisms involved. Lnderstandin,
the pathophysiolo,y o. this disorder/ however/ remains a challen,e/ with the -road ran,e o. symptoms
ma*in, lar,e%scale studies di..icult. <he lac* o. a clear conceptual model hampers the development o.
therapies. Iecent evidence distin,uishin, .ei,nin, .rom conversion disorder/ however/ and pointin, to a
cere-ral inhi-itin, process/ may help patients and their carers accept that they su..er .rom a =real
disease>/ and remove some o. the sti,ma o. =hysteria>. ;n the .uture/ .urther development o.
neuropsycholo,ical models that reconcile the =psychosocial> and the =-iolo,ical> may lead to more speci.ic
and e..ective therapy.
Acknowled!ements
7.6. was supported -y the 7wiss Jational Iesearch 5oundation and I.M. was supported -y the
(ellcome <rust.
Reprint Address
6nthony 7. +avid/ 7ection o. Co,nitive Jeuropsychiatry/ PO 2oA E8/ ;nstitute o. Psychiatry/ Min,8s
Colle,e 'ondon/ +e Crespi,ny Par*/ 'ondon 735 865/ LM <el: N44 20 7 848 0!#8 .aA: N44 20 7 848
0572 e%mail: 6nthony.+avidOiop*clacu*
Selma Aybek/ Richard A. Kanaan/ and Anthony S. David/ 7ection o. Co,nitive Jeuropsychiatry/
;nstitute o. Psychiatry/ Min,8s Colle,e 'ondon/ 'ondon/ LM
Birth order, family size and its association
with conversion disorders
M. Nasar Sayeed Khan1, Salman Ahmad2 & Nadia Arshad3
ABSTACT!
Aims and Objectives: To find out the association of family size and birth order in patients
suffering from conversion disorder, and to observe its correlation with pattern of conversion
symptoms and co morbid anxiety and depressive symptoms
Design: This was a hospital based, descriptive, cross sectional study
!
Place and duration: The study was conducted in the "epartment of #sychiatry, $ervices
hospital, %ahore from &ugust 2''3 to (anuary 2''4
Patients and Methods: )ne hundred patients, suffering from conversion disorder diagnosed on
the basis of "$*+,- criteria were assessed for symptom pattern & semi+structured interview
was used to collect details of family size and birth order &nxiety and "epressive symptoms were
evaluated by using .ospital &nxiety and "epression $cale /.&"$0
Results: The ma1ority of the patients were having 4+! siblings & strong correlation was found
between the larger sized family and the middle born patients with the pattern of the conversion
symptoms as well as with the anxiety and depressive symptoms
Conclusion: The patients with a diagnosis of conversion disorder need to be managed for, not
only the psychological aspects but also the social issues li2e family size and stresses associated
with it
"ey words! 3onversion "isorders, &nxiety, "epression, birth order, family size
#a2 ( *ed $ci (anuary+*arch 2''! -ol 22 4o 1 35+42
J Clin Psychiatry. 2004 Jun;65(6):783-90. 'in*s
%otor conversion disorders reviewed from a neuropsychiatric perspective.
Krem MM.
D!art"nt #$ %ntrnal &'icin( )ashin*t#n +ni,rsity -ch##l #$ &'icin( -t. .#uis( &/ 63000( +-1.
"2r"3i".4ustl.'u
51C678/+9D: C#n,rsi#n 'is#r'r is a s#"at#$#r" 'is#r'r '$in' :y th !rsnc #$
!su'#nur#l#*ic sy"!t#"s rlatin* t# ,#luntary sns#ry #r "#t#r $uncti#n. ;h c#rrct
'ia*n#sis #$ c#n,rsi#n 'is#r'r !rsntin* 4ith "#t#r sy"!t#"s is c#"!licat' :y th lac2
#$ *#l'-stan'ar' 'ia*n#stic tsts an' th a:snc #$ a uni,rsally acc!t' st #$ !#siti,
'ia*n#stic critria. ;his articl r,i4s th !i'"i#l#*y( !ath#!hysi#l#*y( !rsntati#n(
'i$$rntial 'ia*n#sis( trat"nt( an' !r#*n#sis #$ "#t#r c#n,rsi#n( !lacin* "!hasis #n
'ia*n#stic ,ali'ity( rlia:ility( an' utility( 4hil ,aluatin* th "!irical ,i'nc su!!#rtin*
'ia*n#stic an' trat"nt strat*is. D1;1 -/+8C<- 19D -;+D= -<.<C;%/9: .itratur
sarchs 4r carri' #ut in Pu:&' usin* th 2y4#r's c#n,rsi#n 'is#r'r( "#t#r
c#n,rsi#n( 'yst#nia( !sych#*nic( hystria( s#"ati>ati#n( "#ti#n 'is#r'r( "#,"nt
'is#r'r( an' !ath#-!hysi#l#*y. 1rticls an' :##2 cha!trs in th auth#r?s !rs#nal c#llcti#n
4r als# utili>'. C/9C.+-%/9-: 1',ancs in nur#!sychiatric rsarch ar la'in* t#
si*ni$icant i"!r#,"nts in th 'ia*n#sis an' un'rstan'in* #$ "#t#r c#n,rsi#n 'is#r'rs.
P#siti,( #:@cti,( an' Auantitati, 'ia*n#stic critria sh#4 si*ni$icant !r#"is $#r nhancin*
'ia*n#stic accuracy. Currnt !ath#!hysi#l#*ic rsarch has :*un t# !r#,i' "chanistic
6
B!lanati#ns $#r c#n,rsi#n sy"!t#"s( thus :lurrin* th 'istincti#n :t4n !sych#*nic an'
#r*anic "#t#r 'is#r'rs.
$onversion disorder
5rom (i*ipedia/ the .ree encyclopedia
(ump to7 navigation, search
Conversion disorder
Classification and external
resources
ICD#$% 8 44
ICD#& 3''11
DiseasesDB 1!45
e'edicine emerg9112 med9115'
'eS( "''32:1
ICD $%
F44 Dissociative [conversion] disorders
;h c#""#n th"s that ar shar' :y 'iss#ciati, #r c#n,rsi#n
'is#r'rs ar a !artial #r c#"!lt l#ss #$ th n#r"al int*rati#n
:t4n ""#ris #$ th !ast( a4arnss #$ i'ntity an' i""'iat
snsati#ns( an' c#ntr#l #$ :#'ily "#,"nts. 1ll ty!s #$ 'iss#ciati,
'is#r'rs tn' t# r"it a$tr a $4 42s #r "#nths( !articularly i$ thir
#nst is ass#ciat' 4ith a trau"atic li$ ,nt. &#r chr#nic 'is#r'rs(
!articularly !aralyss an' anasthsias( "ay ',l#! i$ th #nst is
ass#ciat' 4ith ins#lu:l !r#:l"s #r intr!rs#nal 'i$$icultis. ;hs
'is#r'rs ha, !r,i#usly :n classi$i' as ,ari#us ty!s #$ Cc#n,rsi#n
hystriaC. ;hy ar !rsu"' t# : !sych#*nic in #ri*in( :in*
ass#ciat' cl#sly in ti" 4ith trau"atic ,nts( ins#lu:l an'
int#lra:l !r#:l"s( #r 'istur:' rlati#nshi!s. ;h sy"!t#"s #$tn
r!rsnt th !atint?s c#nc!t #$ h#4 a !hysical illnss 4#ul' :
5
"ani$st. &'ical Ba"inati#n an' in,sti*ati#n '# n#t r,al th
!rsnc #$ any 2n#4n !hysical #r nur#l#*ical 'is#r'r. %n a''iti#n(
thr is ,i'nc that th l#ss #$ $uncti#n is an B!rssi#n #$ "#ti#nal
c#n$licts #r n's. ;h sy"!t#"s "ay ',l#! in cl#s rlati#nshi! t#
!sych#l#*ical strss( an' #$tn a!!ar su''nly. /nly 'is#r'rs #$
!hysical $uncti#ns n#r"ally un'r ,#luntary c#ntr#l an' l#ss #$
snsati#ns ar inclu'' hr. Dis#r'rs in,#l,in* !ain an' #thr
c#"!lB !hysical snsati#ns "'iat' :y th aut#n#"ic nr,#us
syst" ar classi$i' un'r s#"ati>ati#n 'is#r'r (D45.0). ;h
!#ssi:ility #$ th latr a!!aranc #$ sri#us !hysical #r !sychiatric
'is#r'rs sh#ul' al4ays : 2!t in "in'.
Includes
:
c#n,rsi#n:
E hystria
E racti#n
hystria
hystrical !sych#sis
Excludes
:
"alin*rin* Fc#nsci#us si"ulati#nG ( H76.5 )
Dissociative amnesia
;h "ain $atur is l#ss #$ ""#ry( usually #$ i"!#rtant rcnt
,nts( that is n#t 'u t# #r*anic "ntal 'is#r'r( an' is t## *rat
t# : B!lain' :y #r'inary $#r*t$ulnss #r $ati*u. ;h a"nsia
is usually cntr' #n trau"atic ,nts( such as acci'nts #r
unB!ct' :ra,"nts( an' is usually !artial an' slcti,.
C#"!lt an' *nrali>' a"nsia is rar( an' is usually !art #$ a
$u*u (D44.0). %$ this is th cas( th 'is#r'r sh#ul' : classi$i'
as such. ;h 'ia*n#sis sh#ul' n#t : "a' in th !rsnc #$
#r*anic :rain 'is#r'rs( int#Bicati#n( #r Bcssi, $ati*u.
Excludes
:
alc#h#l- #r #thr !sych#acti, su:stanc-in'uc'
a"nsic 'is#r'r ( D00-D09 4ith c#""#n $#urth
charactr .6)
a"nsia:
E 9/- ( 840.3 )
E antr#*ra' ( 840.0 )
E rtr#*ra' ( 840.2 )
n#nalc#h#lic #r*anic a"nsic syn'r#" ( D04 )
!#stictal a"nsia in !il!sy ( 740.- )
F44.1 Dissociative fugue
:
Diss#ciati, $u*u has all th $aturs #$ 'iss#ciati, a"nsia( !lus
!ur!#s$ul tra,l :y#n' th usual ,ry'ay ran*. 1lth#u*h thr
is a"nsia $#r th !ri#' #$ th $u*u( th !atint?s :ha,i#ur
'urin* this ti" "ay a!!ar c#"!ltly n#r"al t# in'!n'nt
#:sr,rs.
Excludes
:
!#stictal $u*u in !il!sy ( 740.- )
F44.2 Dissociative stupor
Diss#ciati, stu!#r is 'ia*n#s' #n th :asis #$ a !r#$#un'
'i"inuti#n #r a:snc #$ ,#luntary "#,"nt an' n#r"al
rs!#nsi,nss t# Btrnal sti"uli such as li*ht( n#is( an' t#uch(
:ut Ba"inati#n an' in,sti*ati#n r,al n# ,i'nc #$ a !hysical
caus. %n a''iti#n( thr is !#siti, ,i'nc #$ !sych#*nic
causati#n in th $#r" #$ rcnt strss$ul ,nts #r !r#:l"s.
Excludes
:
#r*anic catat#nic 'is#r'r ( D06.0 )
stu!#r:
E 9/- ( 840.0 )
E catat#nic ( D20.2 )
E '!rssi, ( D30-D33 )
E "anic ( D30.2 )
F44.3 Trance and possession disorders
Dis#r'rs in 4hich thr is a t"!#rary l#ss #$ th sns #$
!rs#nal i'ntity an' $ull a4arnss #$ th surr#un'in*s. %nclu'
hr #nly tranc stats that ar in,#luntary #r un4ant'( #ccurrin*
#utsi' rli*i#us #r culturally acc!t' situati#ns.
Excludes
:
stats ass#ciat' 4ith:
E acut an' transint !sych#tic 'is#r'rs ( D23.- )
E #r*anic !rs#nality 'is#r'r ( D07.0 )
E !#stc#ncussi#nal syn'r#" ( D07.2 )
E !sych#acti, su:stanc int#Bicati#n ( D00-D09 4ith
c#""#n $#urth charactr .0)
E schi>#!hrnia ( D20.- )
F44.4 Dissociative motor disorders
%n th c#""#nst ,aritis thr is l#ss #$ a:ility t# "#, th
4h#l #r a !art #$ a li": #r li":s. ;hr "ay : cl#s rs":lanc
t# al"#st any ,arity #$ ataBia( a!raBia( a2insia( a!h#nia(
1'
'ysarthria( 'ys2insia( si>urs( #r !aralysis.
Psych#*nic:
E a!h#nia
E 'ys!h#nia
F44.5 Dissociative convulsions
Diss#ciati, c#n,ulsi#ns "ay "i"ic !il!tic si>urs ,ry cl#sly
in tr"s #$ "#,"nts( :ut t#n*u-:itin*( :ruisin* 'u t# $allin*(
an' inc#ntinnc #$ urin ar rar( an' c#nsci#usnss is
"aintain' #r r!lac' :y a stat #$ stu!#r #r tranc.
F44. Dissociative anaest!esia and sensor" loss
1nasthtic aras #$ s2in #$tn ha, :#un'aris that "a2 it clar
that thy ar ass#ciat' 4ith th !atint?s i'as a:#ut :#'ily
$uncti#ns( rathr than "'ical 2n#4l'*. ;hr "ay :
'i$$rntial l#ss :t4n th sns#ry "#'alitis 4hich cann#t :
'u t# a nur#l#*ical lsi#n. -ns#ry l#ss "ay : acc#"!ani' :y
c#"!laints #$ !arasthsia. .#ss #$ ,isi#n an' harin* ar rarly
t#tal in 'iss#ciati, 'is#r'rs.
Psych#*nic 'a$nss
F44.# Mi$ed dissociative [conversion] disorders
C#":inati#n #$ 'is#r'rs s!ci$i' in D44.0-D44.6
F44.% &t!er dissociative [conversion] disorders
7ansr?s syn'r#"
&ulti!l !rs#nality
Psych#*nic:
E c#n$usi#n
E t4ili*ht stat
F44.' Dissociative [conversion] disorder( unspecified
Conversion disorder is a condition where patients present with neurological symptoms such as
numbness, paralysis, or fits, but where positive physical signs of hysteria can be found ,t is
11
thought that these problems arise in response to difficulties in the patient;s life, and conversion is
considered a psychiatric disorder in the ,nternational $tatistical 3lassification of "iseases and
<elated .ealth #roblems /,3"+1'0
=1>
and "iagnostic and $tatistical *anual of *ental "isorders
4th edition /"$*+,-0
=2>
8ormerly 2nown as ;hysteria;, the disorder has arguably been 2nown for
millennia, though it came to greatest prominence at the end of the 1:th century, when the
neurologist (ean+*artin 3harcot, and psychiatrists #ierre (anet and $igmund 8reud made it the
focus of their study The term ;conversion; has its origins in 8reud;s doctrine that anxiety is
;converted; into physical symptoms
=3>
Though previously thought to have vanished from the west
in the 2'th century, some research has suggested it is as common as ever
=4>
Contents
=hide>
1 "efinition
2 .istory
3 #resentation
4 "iagnosis
o 41 ?xclusion of neurological disease
o 42 ?xclusion of feigning
o 43 ?stablishing a psychological mechanism
5 ?pidemiology
o 51 #revalence
o 52 3ulture
o 53 @ender
o 54 &ge
! Treatment
6 #atient #erspective
5 <eferences
[edit] Definition
"$*+,- defines conversion disorder as follows7
)ne or more symptoms or deficits are present that affect voluntary motor or sensory
function suggestive of a neurologic or other general medical condition
#sychological factors are 1udged, in the clinician;s belief, to be associated with the
symptom or deficit because conflicts or other stressors precede the initiation or
exacerbation of the symptom or deficit & diagnosis where the stressor precedes the onset
of symptoms by up to 15 years is not unusual
The symptom or deficit is not intentionally produced or feigned /as in factitious disorder
or malingering0
12
The symptom or deficit, after appropriate investigation, cannot be explained fully by a
general medical condition, the direct effects of a substance, or as a culturally sanctioned
behavior or experience
The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or warrants medical evaluation
The symptom or deficit is not limited to pain or sexual dysfunction, does not occur
exclusively during the course of somatization disorder, and is not better accounted for by
another mental disorder
The nature of the association between the psychological factors and the neurological symptoms
remains unclear ?arlier versions of the "$*+,- employed psychodynamic concepts, but these
have been incrementally removed from successive versions The ,3"+1' classifies conversion
disorder as dissociative /conversion0 disorder, which suggests the symptoms arise through the
process of dissociation
[edit] History
,n the 1:th century, physicians such as $ilas Aeir *itchell in the B$ and #aul CriDuet and (ean+
*artin 3harcot in 8rance developed ideas about patients sharing unexplained neurological
symptoms 3harcot specialised in treating patients who were suffering from a variety of
unexplained physical symptoms including paralysis, contractures /muscles which contract and
cannot be relaxed0 and seizures $ome of these patients sporadically and compulsively adopted a
bizarre posture /christened arc-de-cercle0 in which they arched their body bac2wards until they
were supported only by their head and their heels
The term E3onversion disorderE originated with 8reud .e viewed these apparently neurological
symptoms as a result of the conversion of intrapsychic distress in to physical symptoms This
distress was thought to cause the brain to unconsciously disable or impair a bodily function as a
side effect of the original repression, which served to relieve the patient;s anxiety
=5>
This is in
contrast to recent evidence that patients remain distressed by their symptoms in the long term
=!>
,t
has been suggested that at least some of the classic psychoanalytic cases of hysteria, such as
E&nna )E
=6>
, may actually have suffered from organic illness
[edit] Presentation
3onversion disorder can present with any motor or sensory symptom including any of the
following7
Aea2ness9paralysis of a limb or the entire body /hysterical paralysis or motor conversion
disorders0
,mpaired hearing or vision
%oss9disturbance of sensation
,mpairment or loss of speech /hysterical aphonia0
#sychogenic non+epileptic seizures
13
8ixed dystonia unli2e normal dystonia
Tremor, myoclonus or other movement disorders
@ait problems /&stasia+abasia0
[edit] Diagnosis
The diagnosis of conversion disorder involves three elements + the exclusion of neurological
disease, the exclusion of feigning, and the determination of a psychological mechanism ?ach of
these has difficulties
&edit' ()clusion of neurolo!ical disease
3onversion disorder presents with symptoms that typically resemble a neurological disorder such
as stro2e, multiple sclerosis, or epilepsy The neurologist must carefully exclude neurological
disease, through examination and appropriate investigations
=5>
.owever, it is not uncommon for
patients with neurological disease to also have conversion disorder
=:>
, in which case the tas2
becomes to determine how much of the patient;s problem is due to conversion
=duious ! discuss>
,n excluding neurological disease, the neurologist has traditionally relied partly on the presence
of positive signs of conversion disorder + certain aspects of the presentation that were thought to
be rare in neurological disease, but common in conversion The validity of many of these signs
has been Duestioned, however, by a study showing that they also occurred in neurological
disease
=1'>
)ne such symptom, for example, is "a elle indiff#rence, described in "$*+,- as Ea
relative lac2 of concern about the nature or implications of the symptomsE ,n a later study no
evidence was found that patients with ;functional; symptoms are any more li2ely to exhibit this
than patients with a confirmed organic disease
=11>
&nother feature thought to be important was
that symptoms would tend to be more severe on the non+dominant /usually left0 sideF there were
a variety of theories such as the relative involvement of cerebral hemispheres in emotional
processing, or more simply 1ust that it was EeasierE to live with a functional deficit on the non+
dominant side .owever, a literature review of 121 studies established that this was not true, with
publication bias the most li2ely explanation for this commonly held view
=12>
The process of exclusion is not perfect, so misdiagnoses will occur .owever, in a highly
influential
=13>
study from the 1:!'s, ?liot $later demonstrated that misdiagnoses had occurred in
one third of his 112 patients with conversion disorder
=14>
%ater authors have argued that the paper
was flawed, however
=15>

=1!>
, and a meta+analysis has shown that misdiagnosis rates since that
paper are around 4G, the same as for other neurological diseases
=16>

&edit' ()clusion of fei!nin!


3onversion disorder is uniDue in "$*+,- in explicitly reDuiring the exclusion of deliberate
feigning Bnfortunately, this is only li2ely to be demonstrable where the patient confesses, or is
;caught out; in a broader deception, such as a false identity
=15>
)ne neuroimaging study suggested
that feigning may be distinguished from conversion by the pattern of frontal lobe activation
=1:>
F
however this is a research, rather than a clinical techniDue True rates of feigning in medicine
14
remain un2nown, though neurological presentations of feigning may be among the more
common
=2'>
&edit' (stablishin! a psycholo!ical mechanism
The psychological mechanism can be the most difficult aspect of the conversion diagnosis
"$*+,- reDuires that the clinician believe preceding stressors or conflicts to be associated with
the development of the disorder, though ho$ this might come about is still the sub1ect of debate
The original 8reudian model
=21>
suggested that the emotional charge of painful experiences would
be consciously repressed as a way of managing the pain, but this emotional charge would be
somehow ;converted; into the neurological symptoms 8reud later argued that the repressed
experiences were of a sexual nature
=22>
&s #eter .alligan comments, conversion has Hthe
doubtful distinction among psychiatric diagnoses of still invo2ing 8reudian mechanisms I
=23>

(anet, the other great theoretician of hysteria, argued that symptoms arose through the power of
suggestion, acting on a personality vulnerable to dissociation
=24>
,n this hypothetical process, the
sub1ect;s experience of their leg, for example, is split+off from the rest of their consciousness,
resulting in paralysis or numbness in that leg %ater authors have attempted to combine elements
of these models, but none of them has a firm empirical basis
=25>
$ome support for the 8reudian
model comes from findings of high rates of childhood sexual abuse in conversion patients
=2!>
and
from a recent neuroimaging study showing abnormal emotion processing of a traumatic event
lin2ed to motor processing of the affected limb, in a patient with conversion
=26>
$upport for the
dissociation model comes from studies showing heightened suggestibility in conversion patients,
=25>
and in abnormalities in motor imagery
=2:>
There has been much recent interest in functional
neuroimaging in conversion &s researchers identify the mechanisms which underlie conversion
symptoms it is hoped these will allow the development of a neuropsychological model &
number of such studies have been performed, including some which suggest that blood flow in
patients brains may be abnormal while they are unwell These have all been too small to be
confident of the generalisability of their findings, however, so that no neuropsychological model
has been clearly established
[edit] Epidemiology
&edit' Prevalence
,nformation on the prevalence of conversion disorder in the Aest is limited, in part due to the
complexities of the diagnostic process ,n neurological settings, rates of unexplained symptoms
are very high, at between 3' and !'G,
=3'>=31>=32>
, which suggests conversion to be more common
than most neurological diseases .owever, the diagnosis of conversion typically reDuires an
additional psychiatric evaluation, yet few patients will see a psychiatrist
=33>
so an un2nown
fraction of those unexplained symptoms will be due to conversion %arge scale psychiatric
registers in the B$ and ,celand found rates of 22 and 11 per 1''''' per year, respectively,
=34>
but
it is unclear what proportion of unexplained symptoms these represent
&edit' $ulture
15
,t is often thought that rates are higher outside of the Aest, perhaps related to cultural and
medical attitudes, though evidence for this is again limited
=35>
& community survey of urban
Tur2ey found a rate of 5!G
=3!>
*any authors have found rates to be higher in rural and lower
socio+economic groups where technological investigation of patients is limited
=36>=35>=3:>
&edit' *ender
;.ysteria; was originally understood to be a condition exclusively affecting women, though it has
increasingly been recognised in men ,n recent, larger studies,
=4'>=41>
women continue to
predominate, with between 2 and ! female patients for every male
&edit' A!e
3onversion disorder may present at any age but is rare in children younger than 1' years or in
the elderly $tudies suggest a pea2 onset in the mid+to+late 3's
=42>=43>=44>

[edit] Treatment
Treatment may include the following
=45>
7
1 ?xplanation This must be clear and coherent as attributing physical symptoms to a
psychological cause is not accepted by many educated people in western cultures ,t must
emphasise the genuineness of the condition, that it is common, potentially reversible and
does not mean that the sufferer is a ;psycho; Ta2ing an aetiologically neutral stance by
describing the symptoms as functional may be helpful but further studies are reDuired
,deally the patient should be followed up neurologically for a while to ensure that the
diagnosis has been understood
2 #hysiotherapy where appropriateF
3 Treatment of comorbid depression or anxiety if present
There is little evidence+based treatment of conversion disorder
=4!>
)ther treatments such as
cognitive behavioral therapy, hypnosis, ?*"<, and psychodynamic psychotherapy need further
trials
[edit] Patient Perspective
*any patients ob1ect to the diagnosis as it does not accord with their experience of the disease
8or a more detailed discussion see wwwconversiondisordercou2
[edit] References
1 ) The ,3"+1' classification of mental and behavioural disorders7 clinical descriptions
and diagnostic guidelines @eneva, Aorld .ealth )rganization, 1::2
2 ) "iagnostic and $tatistical *anual of *ental "isorders, 8ourth ?dition, &merican
#sychiatric &ssociation
3 ) (osef Creuer J $igmund 8reud, E$tudies in .ysteriaE, 15:5
1!
4 ) &2agi, . J .ouse, &), 2''1, The epidemiology of hysterical conversion ,n #
.alligan, 3 Cass, ( *arshall /?ds0 .ysterical 3onversion7 clinical and theoretical
perspectives /pp63+560 )xford7 )xford Bniversity #ress
5 ) Creuer and 8reud, E$tudies in .ysteriaE, 15:5
! ) $tone, et al, %& Soc Med 2''5F &*7546+545
6 ) &lison )rr+&ndrewes, EThe case of &nna )7 & 4europsychiatric perspectiveE, %ournal
of the 'sychoanalytic Association 1:56, vol +, p3::
5 ) $tone (, 3arson &, $harpe *, 2''5, 8unctional symptoms in neurology7 &ssessment,
(ournal of 4eurology, 4eurosurgery and #sychiatry /4eurology in #ractice0F 6! /$uppl
107 2+12
: ) ?ames #, 1::2, E.ysteria following brain in1uryE, (ournal of 4eurology, 4eurosurgery,
and #sychiatry, -ol 55, 1'4!+1'53
1' ) @ould <, *iller C %, @oldberg * &, Censon " 8, 1:5!, The validity of hysterical signs
and symptoms, The (ournal of nervous and mental disease, vol 164, no1', pp 5:3+5:6
11 ) $tone (, $myth <, 3arson &, Aarlow 3, $harpe *, E%a belle indifference in
conversion symptoms and hysteria7 systematic reviewE (r % 'sychiatry 2''! *arF$**
pp2'4+:
12 ) $tone (, $harpe *, 3arson &, %ewis $3, Thomas C, @oldbec2 <, Aarlow 3# E&re
functional motor and sensory symptoms really more freDuent on the leftK & systematic
reviewE % Neurol Neurosur) 'sychiatry. 2''2 4ovF-+/50 pp565+51
13 ) $later, ? E"iagnosis of .ysteriaE(r Med % 1:!5 *ayF $ pp13:5+::
14 ) $later ?T, @lithero ? E& follow+up of patients diagnosed as suffering from ;hysteria; %
'sychosom &es 1:!5 $epF&/10 pp:+13
15 ) <on *, EThe #rognosis of .ysteriaE ,n # .alligan, 3 Cass, ( *arshall /?ds0
.ysterical 3onversion7 clinical and theoretical perspectives /pp63+560 )xford7 )xford
Bniversity #ress
1! ) $tone, et al, %& Soc Med 2''5F &*7546+545
16 ) $tone, et al, (M% 2''5
15 ) Lrahn %, .ongzhe %, );3onnor L E#atients who strive to be ill7 8actitious disorder
with physical symptomsE &merican (ournal of #sychiatry, 2''3F 1!'/!0, pp11!3+5
1: ) $pence $&, 3rimlis2 .%, 3ope ., <on *&, @rasby #* E"iscrete neurophsyiological
correlates in prefrontal cortex during hysterical and feigned disorder of movementE
%ancet 2''' &pr 5F 355/:2110, pp1243+4
2' ) ?c2hardt &, E8actitious disorders in the field of neurology and psychiatryE 1::4F !2/1+
20, pp5!+!2
21 ) (osef Creuer J $igmund 8reud, E$tudies in .ysteriaE, 15:5
22 ) 8reud $, E"ora7 8ragment of an analysis of a case of hysteriaE, 1:'5
23 ) H4ew approaches to conversion hysteria, #eter A .alligan, 3hristopher Cass,"eric2 T
Aade , C*( 2'''F 32'71455 145:, 3 (une
24 ) (anet, # EThe *a1or $ymptoms of .ysteriaE, 1:2', 2nd ?dition
25 ) Crown, <( E#sychological mechanisms of medically unexplained symptoms7 an
integrative conceptual modelE #sychol Cull 2''4 $epF13'/5076:3+512
2! ) <oelofs L, Lei1sers @#, .oogduin L&, 4Mring @A, *oene 83, E3hildhood abuse in
patients with conversion disorderE &m ( #sychiatry 2''2 4ovF15:/11071:'5+13
26 ) Lanaan <&, 3raig TL, Aessely $3, "avid &$ E,maging repressed memories in motor
conversion disorderE #sychosom *ed 2''6 8eb+*arF!:/2072'2+5
16
25 ) <oelofs L, .oogduin L&, Lei1sers @#, 4Mring @A, *oene 83, $andi1c2 # E.ypnotic
susceptibility in patients with conversion disorderE ( &bnorm #sychol 2''2
*ayF111/2073:'+5
2: ) <oelofs L, van @alen @#, Lei1sers @#, .oogduin 3& E*otor initiation and execution
in patients with conversion paralysisE &cta #sychol /&mst0 2''2 *ayF11'/10721+34
3' ) 3arson &(, <ingbauer C, $tone (, *cLenzie %, Aarlow 3, $harpe * E"o medically
unexplained symptoms matterK & prospective cohort study of 3'' new referrals to
neurology outpatient clinicsE ( 4eurol 4eurosurg #sychiatry 2''' 8ebF!5/2072'6+1'
31 ) 4imnuan 3, .otopf *, Aessely $ E*edically unexplained symptoms7 an
epidemiological study in seven specialitiesE ( #sychosom <es 2''1 (ulF51/1073!1+6
32 ) $ni1ders T(, de %eeuw 8?, Llumpers B*, Lappelle %(, van @i1n ( E#revalence and
predictors of unexplained neurological symptoms in an academic neurology outpatient
clinic++an observational studyE ( 4eurol 2''4 (anF251/107!!+61
33 ) 3rimlis2 .%, Chatia L#, 3ope ., "avid &$, *arsden ", <on *& E#atterns of referral
in patients with medically unexplained motor symptomsE ( #sychosom <es 2'''
$epF4:/307216+:
34 ) $tefNnsson (@, *essina (&, *eyerowitz $ E.ysterical neurosis, conversion type7
clinical and epidemiological considerationsE &cta #sychiatrica $candinavica 1:6!
8ebF53/20711:+35
35 ) &2agi, . J .ouse, &), 2''1, The epidemiology of hysterical conversion ,n #
.alligan, 3 Cass, ( *arshall /?ds0 .ysterical 3onversion7 clinical and theoretical
perspectives /pp63+560 )xford7 )xford Bniversity #ress
3! ) "eveci &, Tas2in ), "inc @, Oilmaz ., "emet **, ?rbay+"undar #, Laya ?, )zmen
? E#revalence of pseudoneurologic conversion disorder in an urban community in
*anisa, Tur2eyE $oc #sychiatry #sychiatr ?pidemiol 2''6 4ovF42/1107556+!4
36 ) $tefNnsson (@, *essina (&, *eyerowitz $ E.ysterical neurosis, conversion type7
clinical and epidemiological considerationsE &cta #sychiatrica $candinavica 1:6!
8ebF53/20711:+35
35 ) Tomasson L, Lent ", 3oryell A E$omatization and conversion disorders7 comorbidity
and demographics at presentationE &cta #sychiatrica $candinavica 1::1 $epF54/307255+
:3
3: ) Luloglu *, &tmaca *, Tezcan ?, @ecici ), Culut $ E$ociodemographic and clinical
characteristics of patients with conversion disorder in ?astern Tur2eyE $oc #sychiatry
#sychiatr ?pidemiol 2''3 8ebF35/20755+:3
4' ) "eveci &, Tas2in ), "inc @, Oilmaz ., "emet **, ?rbay+"undar #, Laya ?, )zmen
? E#revalence of pseudoneurologic conversion disorder in an urban community in
*anisa, Tur2eyE $oc #sychiatry #sychiatr ?pidemiol 2''6 4ovF42/1107556+!4
41 ) 3arson &(, <ingbauer C, $tone (, *cLenzie %, Aarlow 3, $harpe * E"o medically
unexplained symptoms matterK & prospective cohort study of 3'' new referrals to
neurology outpatient clinicsE ( 4eurol 4eurosurg #sychiatry 2''' 8ebF!5/2072'6+1'
42 ) 3arson &(, <ingbauer C, $tone (, *cLenzie %, Aarlow 3, $harpe * E"o medically
unexplained symptoms matterK & prospective cohort study of 3'' new referrals to
neurology outpatient clinicsE ( 4eurol 4eurosurg #sychiatry 2''' 8ebF!5/2072'6+1'
43 ) $tefNnsson (@, *essina (&, *eyerowitz $ E.ysterical neurosis, conversion type7
clinical and epidemiological considerationsE &cta #sychiatrica $candinavica 1:6!
8ebF53/20711:+35
15
44 ) "eveci &, Tas2in ), "inc @, Oilmaz ., "emet **, ?rbay+"undar #, Laya ?, )zmen
? E#revalence of pseudoneurologic conversion disorder in an urban community in
*anisa, Tur2eyE $oc #sychiatry #sychiatr ?pidemiol 2''6 4ovF42/1107556+!4
45 ) $tone (, 3arson &, $harpe * E8unctional symptoms in neurology7 managementE (
4eurol 4eurosurg #sychiatry 2''5 *arF6! $uppl 17i13+21
4! ) <uddy and .ouse, 3ochrane 3ollaboration
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%edical (ncyclopedia+ $onversion disorder
LI' o. this pa,e: http799wwwnlmnihgov9medlineplus9ency9article9''':54htm
Alternative names
Fysterical neurosis
Definition
3onversion disorder is a condition in which a person has blindness, paralysis, or other nervous
system /neurologic0 symptoms that cannot be explained
$auses, incidence, and risk factors
3onversion disorder symptoms may occur because of emotional distress or psychological
problems
$ymptoms usually begin suddenly after a stressful experience #eople are more at ris2 for a
conversion disorder if they also have a medical illness, dissociative disorder, or personality
disorder
$ome doctors falsely believe that conversion disorder and similar disorders are not real
conditions, and may tell patients that the problem is Eall in your headE .owever, these
conditions are real They cause distress and cannot be turned on and off at will <esearch on the
mind+body connection may eventually increase understanding of these disorders
Symptoms
1:
$ymptoms of a conversion disorder include the loss of one or more bodily functions, such as7
2lindness
;na-ility to spea*
Jum-ness
Paralysis
"iagnostic testing does not find any physical cause for the symptoms
Si!ns and tests
3ommon signs of conversion disorder include7
6 de-ilitatin, symptom that -e,ins suddenly
6 history o. a psycholo,ical pro-lem that ,ets -etter a.ter the symptom appears
6 lac* o. concern that usually occurs with a severe symptom
Oour doctor will do a physical examination, and possibly diagnostic tests, to rule out physical
causes for the symptom
"reatment
#sychotherapy and stress management training may help reduce symptoms The affected body
part or physical function will need physical or occupational therapy until the symptoms
disappear 8or example, paralyzed limbs must be exercised to prevent muscle wasting
()pectations -pro!nosis.
$ymptoms usually last for days to wee2s and may suddenly go away Bsually the symptom itself
is not life threatening, but complications can be debilitating
$allin! your health care provider
3all for an appointment with your health care provider if you or someone you 2now has
symptoms of a conversion disorder
References
*oore "#, (efferson (A 3onversion disorder ,n7 *oore "#, (efferson (A, eds *andoo+ of
Medical 'sychiatry 2nd ed #hiladelphia, #a7 *osby ?lsevierF 2''47 chap :1
8erri 88 3onversion disorder ,n7 8erri 88, ed ,erri-s Clinical Ad.isor 2//01 2nstant 3ia)nosis
and 4reatment 1st ed #hiladelphia, #a7 *osby ?lsevierF 2''5
/pdate Date+ 0120324115
Lpdated -y: 'inda @orvic*/ ?+/ 7eattle 7ite Coordinator/ 'ecturer/ Pathophysiolo,y/ ?3+3P Jorthwest +ivision o. Physician
6ssistant 7tudies/ Lniversity o. (ashin,ton 7chool o. ?edicine and <imothy 6. Io,,e/ ?+/ private practice in Psychiatry/ Mir*land/
(ashin,ton. 6lso reviewed -y+avid Qieve/ ?+/ ?F6/ ?edical +irector/ 6.+.6.?./ ;nc.
2'
March, 2007 Note: Most of my articles on temperament, dreams, psychology, etc. are now hosted at
www.neurocareusa.com. Go there for the latest version of articles. However, the lins to old versions are
still functional.!
(iner 5oundation/ Jeurocare/ and C.G. Run, Center o. Philadelphia president is
Philadelphia and +elaware valley neurolo,ist/ psychiatrist/ psychopharmacolo,ist/ and
psychotherapist Io-ert ;. (iner/ ?.+./ a medical doctor specialist in neurolo,y/
psychiatry/ psychotherapy/ and psychopharmacolo,y. +r. (iner is Run,ian%oriented
psychotherapist "usin, the approach o. psychiatrist Carl Run, $ ma*in, use o. dreams %
dream interpretation % to wor* with the unconscious in therapy/ psychotherapy/ analysis/
or psychoanalysis.
%alin!erin! and $onversion Reactions -4114.
by Robert I. 6iner, %.D.
Introduction
;n the medical%le,al arena/ medical specialists/ physical therapists/ and psychiatrists are
o.ten called upon to ma*e an assessment that renders an opinion as to the whether a
patient8s complaints or e..orts are or,anically/ psychiatrically/ or pain%-ased. ;n particular/
the psychiatric side o. this e4uation o.ten is the decision o. whether the clinical
presentation is the result o. conscious .ei,nin,/ what is called Smalin,erin,.S @arious
clinical tests have -een desi,ned to assess the so%called Struth.ulnessS o. a patient8s
pain or the SactualityS o. the de,ree o. e..ort they put .orth which may -e termed the
SvalidityS .or or,anicity o. the test.
;t is my sense that the main di..iculty is that the ma0ority o. practitioners ma*in, these
decisions have too small a *nowled,e -ase and lac* the clinical -readth to understand
properly the scope o. the clinical material that one may encounter. ; ;n particular/ it
seems to me that the main pro-lem is the one%sided conception that a pro-lem is either
in the mind or the -ody. ?odern medicine has -ecome .illed with splitters %% those who
.or the sa*e o. ma*in, clear dia,nostic criteria have ar-itrarily decided that some
conditions are physical "or use the term or,anic$ while others are mental "also called
.unctional$. O. course there is truth to this/ however/ clinicians must .ace the .act that the
-ody and psyche are irrevoca-ly lin*ed. <his has -een repeatedly proven scienti.ically
and eAperimentally. <he plain .act is that all o. humanity mani.ests/ at one time or
another/ psychic distur-ances in -odily .orm. 6 eAample is the physical symptoms o. an
emotional Sstomach ache.S +epth psycholo,y understands emotions as a .eelin,%tone
accompanied -y -odily activation/ the most common -ein, tears or lau,hter. 5or more
on this/ see my writin,s on the .our .unctions o. sensin,/ intuition/ thin*in,/ and .eelin,.
%alin!erin!
?alin,erin, is dia,nosed when the eAaminer is convinced that a patient mani.ests .alse
21
or ,rossly eAa,,erated physical and/or psycholo,ical symptoms and / or si,ns. <he
symptoms are presumed to -e under voluntary control and are said to -e .ei,ned or
em-ellished -ecause o. a conscious desire to achieve or maintain some .inancial or
addictionally%driven ,ain or to avoid some unpleasant conse4uences "wor*/ conscription
to militiary service/ imprisonment/ dru, withdrawal$.
<o dia,nose malin,erin,/ it is also assumed that the eAaminer either *nows with
certainty that -oth the symptoms are .ei,ned / em-ellished "via surveillance$ and that
the ,ain or avoidance is clearly discerni-le ,iven the circumstances o. the patient.
;. malin,erin, were the correct dia,nosis in a medical le,al case "which is the type o.
0ud,ment that most eAperts practicin, in this .ield are as*ed to ma*e$/ then one could
eApect prompt resolution o. the si,ns and symptoms once the cash award ta*es place or
i. the need .or .ei,nin, ceases. ; t is surprisin, how this is not the case in many patients
who have -een suspected as malin,ers -y eAperts. (hen the clinical symptomatolo,y
remains consistent .or a lon, period o. time/ despite the completion o. a medical%le,al
settlement/ one must seriously consider another dia,nosis.
O.ten times/ non%psychiatric physicians note an alle,ed disparity -etween certain
physical si,ns/ such as ,ait or movements/ durin, their physical eAamination. <hey use
this as SevidenceS o. malin,erin, or Ssymptom em-ellishmentS "a particular ir*some
phrase which is as va,ue and su-0ective as it sounds$. 7ometimes an eAaminer will say
that movements appeared di..erent when Sthe patient -elieved they were not -ein,
o-served.S <hen this alle,ed SdisparityS is cited as SevidenceS o. malin,erin,/ without
any attempt to ma*e an empirical eAplanation o. the phenomenon. O. course/
malin,erin, is one possi-ility and it should -e considered. Fowever/ most o. the time/
the physician involved "here ; am tal*in, a-out a neurolo,ist/ orthopedic sur,eon/ or
physiatrist$ has little or even no pro.essional trainin, in psychiatry / psycholo,y other
than their own eAperience as a clinican in their .ireld. 7peci.ically/ in all patient%doctor
contacts there is a distinct psychodynamic which has nuances dependin, upon whether
the encounter is part o. a re,ular patient%doctor relationship/ ;?3/ or some other
relationship%contract. <ypically these so%called discrepancies are characteriBed -y
ver-ia,e such as this:
S<he o-served inconsistencies in her -ehavior inside and outside the clinic su,,ests that
she may have more stren,th then the patient is willin, to admit. 7he did not seem to -e
cooperatin, .ully in the eAamination.S
Other alle,ed si,ns o. disparity ta*e place in conditions o. co,nitive dys.unction. Fere8s
another eAcerpt .rom a physician note:
S<he patient was lucid in some responses despite her complaint o. con.usion. <his
points to symptom ma,ni.ication.S
22
"iscussion
+o disparities in eAamination in di..erent environments esta-lish the dia,nosis o.
malin,erin,K <he answer is emphatically no. Fowever i. these o-servations are
accurate o-servations/ they do provide important dia,nostic in.ormation. <hese Sso%
calledS discrepitancies/ i. viewed .rom a psycholo,ical point o. view/ are evidence o.
psycholo,ical .actors -ein, operational.
Conversion disorder
<he dia,nosis o. conversion disorder demands a clear temporal lin* to a traumatic event
or a tri,,er to activate the psychiatric response to a previous traumatic event. <he
eAaminer must also .ind these events or tri,,ers to -e o. a su..icient severity at the time
o. the onset o. symptoms or si,ns to -e the causal .actors.
7omatiBation disorder
7omaBation disorder can sometimes -e an attractive dia,nosis in medical%le,al cases
suspected o. malin,erin,. ;n re,ard to symptom compleA/ one must per.orm a care.ul
chec*list to see i. a patient meets the +7?%;@ criteria .or this dia,nosis and that the
symptoms are o. a su..icient severity to si,ni.icantly alter li.e style.
Fypochondrical .eatures may also -e part o. the clinical picture in patients suscepted o.
malin,erin,. ;n hypochondriasis/ patients have an unrealistic interpretation o. their
physical complaints/ alon, with a pre%occupation with their perception o. -ein, ill.
7ome suspected malin,erers also have .eatures o. schiBotypical -ehavior such as social
isolation/ odd speech/ inade4uate rapport in .ace%to%.ace interaction due to constricted
a..ect and compulsive/narcissistic .eatures such as per.ectionism and preoccupation
with details/ .iAation on her -odily complaint and drawin, o. attention to themselves in
the outside world and in the clinical doctor/patient relationship.
Copyri,ht/ 2002
Io-ert ;. (iner/ ?.+.
emedicine.medscape.com
&'icin -!cialtis I <"r*ncy &'icin I Psych#s#cial
Conversion Disorder
23
Seth Powsner, %D, Pro.essor o. Psychiatry and 3mer,ency ?edicine/ Tale Lniversity 7chool o. ?edicine ?edical
+irector/ Crisis ;ntervention Lnit/ 7ection o. 3mer,ency ?edicine/ Tale%Jew Faven Fospital
Susan Dufel, %D, A$(P, Pro,ram +irector/ 6ssociate Pro.essor/ +epartment o. <raumatolo,y and 3mer,ency ?edicine/
+ivision o. 3mer,ency ?edicine/ Lniversity o. Connecticut 7chool o. ?edicine
Lpdated: Jov 4/ 2008
)ntroduction
*ac+ground
Conversion disorder is classi.ied as one o. the somato.orm disorders in the "iagnostic and #tatistical Manual
of Mental "isorders of the $merican %sychiatric $ssociation, &ourth 'dition, (e)t *evision +"#M,-.,(*!.
6lthou,h de.ined as a condition that presents as an alteration or loss o. a physical .unction su,,estive o. a
physical disorder/ conversion disorder is presumed to -e the eApression o. an underlyin, psycholo,ical con.lict
or need.
<he critical psycholo,ical con.lict or stress may not -e apparent initially/ -ut it -ecomes evident in the course o.
o-tainin, a patient>s history: ideally/ it is a psycholo,ical .actor related sym-olically and temporally to symptom
onset. Conversion symptoms are presumed to result .rom an unconscious process. "Conscious/intentional
production o. physical symptoms is classi.ied as .actitious disorder or malin,erin,.$ Conversion symptoms are
not considered to -e under voluntary control/ and/ should not -e eAplained -y any physical disorder or *nown
patholo,ical mechanism "a.ter appropriate medical evaluation$.
<hou,h classi.ied with somato.orm disorders includin, hypochondriasis and -ody dysmorphic disorder in "#M,
--- and "#M,-./ conversion disorder is classi.ied as a dissociative disorder in ;C+%!0/ *eepin, its lon,
association with hysteria "+issociative +isorders in "#M,-.$. Clinical descriptions o. conversion disorder date
to almost 4000 years a,o the 3,yptians attri-uted symptoms to a Swanderin, uterus.S ;n the !Hth century/ Paul
2ri4uet descri-ed the disorder as a dys.unction o. the CJ7. 5reud .irst used the term conversion to re.er to the
development o. a somatic symptom to help -ind anAiety around a repressed con.lict.
5or related in.ormation/ see ?edscape8s Psychiatry and ?ental Fealth 7pecialty pa,e.
,at!op!"siolog"
Presentin, symptoms can ran,e .ar across the .ield o. clinical neurolo,y. Conversion reactions usually
approAimate lesions in the nervous system>s voluntary motor or sensory pathways. 7ymptoms most commonly
reported are wea*ness/ paralysis/ pseudoseiBures/ involuntary movements "e,/ tremors$/ and sensory
distur-ances. <hese losses or distortions o. neurolo,ic .unction cannot ade4uately -e accounted .or -y or,anic
disease. 5unctional ?I; ".?I;$ and transcranial ma,netic stimulation "<?7$ studies have shown di..erent
activation patterns in patients with conversion symptoms and healthy control su-0ects this is in *eepin, with
the SinvoluntaryS nature o. conversion symptoms.
!/ 2
Patient8s whose symptoms are limited to pain or seAual
.unctionin, are not classi.ied under conversion disorder li*ewise/ patients already classi.ied as demonstratin,
somatiBation disorder or schiBophrenia are also not classi.ied under conversion disorder.
+ia,nostic criteria .or conversion disorder as de.ined in the "#M,-. are as .ollows:
One or more symptoms or de.icits are present that a..ect voluntary motor or sensory .unction that
su,,est a neurolo,ic or other ,eneral medical condition.
Psycholo,ic .actors are 0ud,ed to -e associated with the symptom or de.icit -ecause con.licts or other
stressors precede the initiation or eAacer-ation o. the symptom or de.icit.
24
<he symptom or de.icit is not intentionally produced or .ei,ned "as in .actitious disorder or
malin,erin,$.
<he symptom or de.icit/ a.ter appropriate investi,ation/ cannot -e eAplained .ully -y a ,eneral medical
condition/ the direct e..ects o. a su-stance/ or as a culturally sanctioned -ehavior or eAperience.
<he symptom or de.icit causes clinically si,ni.icant distress or impairment in social/ occupational/ or
other important areas o. .unctionin, or warrants medical evaluation.
<he symptom or de.icit is not limited to pain or seAual dys.unction/ does not occur eAclusively durin,
the course o. somatiBation disorder/ and is not -etter accounted .or -y another mental disorder.
6ccordin, to psychodynamic theory/ conversion symptoms develop to de.end a,ainst unaccepta-le impulses.
<he primary ,ain/ that is to say the purpose o. a conversion symptom is to -ind anAiety and *eep a con.lict
internal. 6 .airly transparent eAample would -e le, paralysis a.ter an e4uestrian competitor is thrown .rom his or
her horse. <he symptom has a sym-olic value that is a representation and partial solution o. a deep%seated
psycholo,ical con.lict: to avoid runnin, away li*e a coward/ and yet to avoid -ein, thrown a,ain.
6ccordin, to learnin, theory/ conversion disorder symptoms are a learned maladaptive response to stress.
Patients achieve secondary ,ain -y avoidin, activities that are particularly o..ensive to them/ there-y ,ainin,
support .rom .amily and .riends/ which otherwise may not -e o..ered.
Fre-uenc"
.nited /tates
<rue conversion reaction is rare. Predisposin, .actors include eAtreme psychosocial stress/ and perhaps/ rural
up-rin,in,. 7ome psychiatrists suspect that western society has incorporated 5reudian notions o. unconscious
motivations and con.licts: conversion reactions have -ecome too o-vious to serve their purpose.
;ncidence has -een reported to -e !!%#00 cases per !00/000 people.
Cultural .actors may play a si,ni.icant role. 7ymptoms that mi,ht -e considered a conversion disorder
in the L7 may -e a normal eApression o. anAiety in other cultures.
One study reports that conversion disorder accounts .or !.2%!!.5C o. psychiatric consultations .or
hospitaliBed medical and sur,ical patients.
)nternational
6t the Jational Fospital in 'ondon/ the dia,nosis was made in !C o. inpatients. ;celand8s incidence o.
conversion disorder is reported to -e !5 cases per !00/000 persons.
Mortalit"0Mor1idit"
Patients dia,nosed with conversion disorder may ,o on to demonstrate serious/ traditional medical illness. <his
has -een happenin, less and less o.ten over the years "2HC in !H50s down to 4C in !HH0s$. Ln.ortunately/
emer,ency physicians may .ind themselves sortin, out new neurolo,ic symptoms in settin,s o. terri-le time
pressure: populations statistics may -e o. little reassurance .or any speci.ic individual.
/e$
7eA ratio is not *nown althou,h it has -een estimated that women patients outnum-er men -y E:!. <his is o.
little help when evaluatin, an individual patient.
2ge
25
Conversion disorder may present at any a,e -ut is rare in children youn,er than !0 years or in
persons older than #5 years.
;n a Lniversity o. ;owa study o. #2 patients with conversion disorder/ however/ the mean a,e was 4!
years with a ran,e o. 2#%58 years.
;n pediatric patients/ incidence o. conversion is increased a.ter physical or seAual a-use. ;ncidence
also increases in those children whose parents are either seriously ill or have chronic pain.
3linical
4istor"
+e,ree o. impairment usually is mar*ed and inter.eres with daily li.e activities. Prolon,ed loss o. .unction may
produce or,anic complications such as disuse atrophy or contractures.
(ea*ness/ paralysis/ pseudoseiBures/ involuntary movements "e,/ tremors$/ and sensory
distur-ances "e,/ aphonia/ dea.ness/ -lindness$ are the most .re4uent complaints. 7ymptoms o.ten
ena-le patients to avoid an unpleasant situation at home or wor*/ attract attention/ or ,ain support
.rom others. <his may -ecome evident throu,h care.ul 4uestionin,.
<he symptom must not -e under voluntary control. +eterminin, the symptom may -e di..icult/ since it
usually cannot -e identi.ied -y o-servation. 5eatures su,,estive o. voluntary control consist o.
varia-ility/ inconsistency/ o-vious and immediate -ene.it/ as well as a personality that may su,,est
dishonesty and opportunism. 7ymptoms/ i. voluntary/ tend to -e sel.%limited and o. -rie. duration.
'a -elle indi..Urence was considered a classic .eature o. conversion disorder. ;t is characteriBed -y the
inappropriate and paradoAical a-sence o. distress despite the presence o. an unpleasant symptom.
Patients o.ten deny emotional di..iculty. Ln.ortunately/ la -elle indi..Urence/ histrionic personality/ and
secondary ,ain are clinical .eatures that appear to have no dia,nostic si,ni.icance. <hey can easily -e
a-sent in patients with conversion disorder they can -e easily -e present in patients with traditional
neurolo,ic disorder.
One study reported 5 patients with hysterical conversion reactions a.ter in0ury or in.arction to the le.t
cere-ral hemisphere.
,!"sical
6-sence o. a physical disorder is an important dia,nostic .eature. ;ndividuals with conversion disorder o.ten
have physical si,ns -ut lac* o-0ective neurolo,ical si,ns to su-stantiate their symptoms.
(ea*ness
o (ea*ness usually involves whole movements rather than muscle ,roups. (ea*ness a..ects
the eAtremities more o.ten than ocular/ .acial/ or cervical movements.
o (ith the use o. various clinical techni4ues/ wea*ness o. one lim- can -e demonstrated to
cause contraction o. opposin, muscle ,roups. +iscontinuous resistance durin, testin, o.
power or ,ive%way wea*ness may eAist. ?uscle wastin, is a-sent/ and re.leAes are normal.
7ensory symptoms
o 7ensory loss or distortion o.ten is inconsistent when tested on more than one occasion and is
incompati-le with peripheral nerve or root distri-ution.
o +iscrete patches o. anesthesia or hemisensory loss that stop in the midline may -e present.
o Classic dermatomes in patients with num-ness usually are not .ollowed.
@isual symptoms
2!
o @isual symptoms include monocular diplopia/ triplopia/ .ield de.ects/ tunnel vision/ and
-ilateral -lindness associated with intact pupillary re.leAes.
o Opto*inetic nysta,mus may -e o-served in patients with apparent -lindness when eAposed to
a rotatin, striped drum.
Gait distur-ances
o 6stasia%a-asia is a motor coordination disorder characteriBed -y the ina-ility to stand despite
normal a-ility to move le,s when lyin, down or sittin,.
o Patients wal* normally i. they thin* they are not -ein, o-served.
o Occasionally/ while -ein, o-served/ patients actively attempt to .all. <his contrasts with those
patients with or,anic disease who attempt to support themselves.
PseudoseiBures
o +urin, an attac*/ mar*ed involvement o. the truncal muscles with opisthotonos and lateral
rollin, o. the head or -ody is present. 6ll 4 lim-s may eAhi-it random thrashin, movements/
which may increase in intensity i. restraint is applied.
o Cyanosis is rare unless patients deli-erately hold their -reath.
o Ie.leAes "e,/ pupillary/ corneal$ are retained -ut may -e di..icult to test due to ti,htly closed
lids.
o <on,ue -itin, and incontinence are rare unless the patient has some de,ree o. medical
*nowled,e a-out the natural course o. the disease.
o ;n contrast to true seiBures/ pseudoseiBures primarily occur in the presence o. other people
and not when the patient is alone or asleep.
3auses
<rue etiolo,y is un*nown. ?ost clinicians presume conversion reactions are caused -y previous
severe stress/ emotional con.lict/ or an associated psychiatric disorder.
?any studies con.irm hi,h incidence o. depression in patients with conversion disorder. 6s many as
hal. o. these patients have personality disorders or display hysterical traits.
;n children/ conversion disorder o.ten is o-served .ollowin, physical or seAual a-use.
Children who have .amily mem-ers with a history o. conversion reactions are more li*ely to su..er .rom
conversion disorder. ;n addition/ i. .amily mem-ers are seriously ill or in chronic pain/ children are more
li*ely to -e a..ected.
Differential Diagnoses
6drenal ;nsu..iciency and 6drenal Crisis ?ultiple 7clerosis
6myotrophic 'ateral 7clerosis ?yasthenia Gravis
2ell Palsy Jeoplasms/ 7pinal Cord
2eni,n Positional @erti,o Jeuroleptic ?ali,nant 7yndrome
2rain 6-scess Panic +isorders
Cauda 34uina 7yndrome Pediatrics/ Child 6-use
C2IJ3 % 2otulism Ia-ies
Central @erti,o 7pinal Cord ;n.ections
Cysticercosis 7yphilis
+elirium/ +ementia/ and 6mnesia <ic*%2orne +iseases/ 'yme
3ncephalitis <oAicity/ Ci,uatera
26
3pidural and 7u-dural ;n.ections <oAicity/ ?edication%;nduced +ystonic Ieactions
3pidural Fematoma <oAicity/ ?ercury
Guillain%2arrU 7yndrome <oAicity/ Jeuroleptic 6,ents
Ferpes 7impleA <oAicity/ 7elective 7erotonin Ieupta*e ;nhi-itor
Ferpes 7impleA 3ncephalitis <ransient ;schemic 6ttac*
Funtin,ton Chorea @esti-ular Jeuronitis
'am-ert%3aton ?yasthenic 7yndrome (ithdrawal 7yndromes
'um-ar ";nterverte-ral$ +is* +isorders
?eniere +isease
&t!er ,ro1lems to *e 3onsidered
Cere-ellopontine an,le tumors
@erte-ro-asilar insu..iciency
CreutB.eldt%Ra*o- disease
6cute compressive optic neuropathy
5or+up
6a1orator" /tudies
Care.ully consider the possi-ility o. an or,anic etiolo,y.
7ome authors have su,,ested that unnecessary/ pain.ul/ or invasive testin, can result in
rein.orcement and .iAation o. symptoms and should -e avoided when possi-le.
Consider la-oratory testin, to eAclude the .ollowin, clinical entities:
o 3lectrolyte distur-ances
o Fypo,lycemia
o Fyper,lycemia
o Ienal .ailure
o 7ystemic in.ection
o <oAins
o Other dru,s
)maging /tudies
6 chest A%ray "CPI$ may -e considered to dia,nose an occult neoplasm.
C< scan or ?I; may -e per.ormed to eAclude a space%occupyin, lesion in the -rain or spinal cord.
&t!er Tests
6n electroencephalo,raph may help distin,uish pseudoseiBures .rom a true seiBure disorder.
,rocedures
7pinal .luid may -e dia,nostic in rulin, out in.ectious or other causes o. neurolo,ic symptoms.
Treatment
,re!ospital 3are
25
<reat patients as i. their symptoms have an or,anic ori,in. Prehospital personnel most o.ten cannot distin,uish
a conversion reaction .rom an or,anic illness.
7mergenc" Department 3are
3mer,ency physicians must -e aware that the dia,nosis o. conversion disorder does not eAclude the presence
o. underlyin, disease/ and dia,nosis should not -e made solely on the -asis o. ne,ative wor*up results.
6pproach each patient as i. their symptoms had an or,anic -asis/ and treat them accordin,ly.
3onsultations
Consultation is o.ten necessary and should -e considered durin, 3+ dischar,e plannin, .or any patients
without previous histories o. conversion reaction.
Consultation may -e a cost%e..ective method to eliminate unnecessary hospitaliBation -y streamlinin,
these patients to appropriate outpatient psychiatric .ollow%up.
Jeurolo,ic consultation may help i. the neurolo,ical eAamination is e4uivocal.
Psychiatric consultation may -e necessary i. an or,anic cause is virtually eAcluded. <hou,ht.ul
4uestionin, may elicit the underlyin, stressor.
6nother treatment techni4ue is su,,estive therapy: an authoritative/ not con.rontative/ pronouncement
that Sthis pro-lem usually resolves in a .ew hoursS is o.ten success.ul/ especially with children.
6ppropriate attention/ .or eAample/ repeated vital si,ns plus ad0unctive antianAiety medication/ can
increase odds o. success with adults.
Other su,,estive therapies .or symptom removal include hypnosis and amo-ar-ital interviews. Lsin, a
-ehaviorally oriented treatment strate,y/ the ,oals are to unlearn maladaptive responses and to learn
more appropriate responses. 6ttempt to eliminate the patient8s -elie. that the eAtremity is paralyBed -y
tellin, the patient "!$ that all tests indicate the muscles and nerves are .unctionin, normally/ "2$ the
-rain is communicatin, with the nerves and muscles/ and "#$ this apparent lost a-ility is recovera-le.
Con.rontin, the patient with the .act that the symptoms are not or,anic is counterproductive.
Medication
+ru, therapy has not proven relia-le. Fowever/ a num-er o. psychiatrists recommend a sedative or antianAiety
a,ent. ;t is usually easiest to ,ive a -enBodiaBepine/ e,/ loraBepam 0.5%! m, "alon, with a su,,estion that
symptoms are li*ely to remit in an hour or so$. 6mo-ar-ital is .allin, out o. .avor as a sedative/ or .or an 6mytal
interview/ -ut has -een a traditional medication.
Follo89up
Furt!er &utpatient 3are
6ny patient dia,nosed with a conversion reaction in the 3+ should -e encoura,ed to pursue
psychiatric .ollow%up. <his can -e su,,ested as a way to reduce and mana,e stress and miti,ate
eAacer-ation o. physical symptoms "side%steppin, ar,uments a-out etiolo,y o. symptoms$. Psychiatric
.ollow%up is especially help.ul .or rare cases o. more serious psychiatric syndromes presentin, to an
emer,ency department with physical symptoms.
?any patients have spontaneous remission a.ter outpatient psychotherapy or su,,estive therapy.
6s o. yet/ there are no well%esta-lished treatment re,imens .or conversion disorder. <here has -een
more success with the other somato.orm disorders.
2:
Transfer
6ll trans.ers must comply with Consolidated Omni-us 2ud,et Ieconciliation 6ct "CO2I6$/3mer,ency
?edical <rans.er and 6ctive 'a-or 6ct "3?<6'6$ re,ulations "see CO2I6 'aws and 3?<6'6$.
3omplications
3rrors in dia,nosis o. conversion disorder are not uncommon. (ith newer dia,nostic testin,/ instances
o. .alse%positive dia,noses o. conversion disorder in which a neurolo,ical disease is later identi.ied are
around 4C.
Iecent studies have .ound a variety o. or,anic diseases in patients who were initially dia,nosed with
conversion disorder. ;n one case report/ a woman reportin, le, wea*ness and -ac* pain was
su-se4uently dia,nosed with sporadic CreutB.eldt%Ra*o- disease. Other patients with underlyin,
psychiatric illnesses were .ound to have dis* herniations/ epidural a-scesses/ or cere-ral
hemorrha,es. ;n another case series/ 5 patients were identi.ied as havin, sarcoma%induced
osteomalacia/ cere-ellar medullo-lastoma/ Funtin,ton chorea/ transverse myelitis/ and lower eAtremity
dystonia. 6lthou,h these case reports were rare/ the initial dia,nosis o. conversion disorder without a
complete neurolo,ic eAamination/ appropriate ima,in,/ and other dia,nostic testin, should -e
discoura,ed.
,rognosis
Pro,nostic studies di..er in outcome/ with recovery rates ran,in, .rom !5%74C. 5actors associated with
.avora-le outcomes are male ,ender/ acute onset o. symptoms/ precipitation -y a stress.ul event/
,ood premor-id health/ and an a-sence o. or,anic or psychiatric disorder.
?any patients with conversion reactions have spontaneous remission or demonstrate mar*ed or
complete recovery a.ter -rie. psychotherapy.
Miscellaneous
Medicolegal ,itfalls
Lnderlyin, or,anic disease may -e present in patients with conversion disorder. 3rrors in dia,nosis
may -e as much as 25C/ especially with the limited time and testin, availa-le in the 3+. ;. uncertain
as to the etiolo,y o. the patient8s symptoms or uncom.orta-le with a complicated neurolo,ic
presentation/ see* appropriate neurolo,ic and psychiatric consultation.
:eferences
!. 7tone R/ Qeman 6/ 7imonotto 3/ et al. 5?I; in patients with motor conversion symptoms and controls
with simulated wea*ness. %sychosom Med. +ec 2007EH"H$:HE!%H. 9?edline:.
2. 'iepert R/ Fassa </ <uscher O/ et al. 3lectrophysiolo,ical correlates o. motor conversion disorder. Mov
"isord. 7ep !0 20089?edline:.
#. 6merican Psychiatric 6ssociation. "iagnostic and #tatistical Manual of Mental "isorders, &ourth
'dition, (e)t *evisions. (ashin,ton +C: 6merican Psychiatric 6ssociation 2000.
3'
4. 2inBer ?/ 6ndersen P?/ Mull,ren G. Clinical characteristics o. patients with motor disa-ility due to
conversion disorder: a prospective control ,roup study. / Neurol Neurosurg
%sychiatry. Rul !HH7E#"!$:8#%8. 9?edline:.
5. 2inBer ?/ Mull,ren G. ?otor conversion disorder. 6 prospective 2% to 5%year .ollow%up
study. %sychosomatics. Jov%+ec !HH8#H"E$:5!H%27. 9?edline:.
E. 2reuer R/ 5reud 7. 7tudies on hysteria. ;n: (ranslated from the German and edited 0y /ames #trachey,
in colla0oration with $nna &reud, assisted 0y $li) #trachey and $lan (yson. 1ase - &r2ulein $nna 3.
+4reuer!. Jew Tor*: 2asic 2oo*s !H57:2!.
7. 2rown IR/ Cardena 3/ Ji0enhuis 3/ et al. 7hould conversion disorder -e reclassi.ied as a dissociative
disorder in +7? @K. %sychosomatics. 7ep%Oct 200748"5$:#EH%78. 9?edline:.
8. +ra*e ?3 Rr. Conversion hysteria and dominant hemisphere lesions. %sychosomatics. Jov%
+ec !HH##4"E$:524%#0. 9?edline:.
H. +ula +R/ +eJaples '. 3mer,ency department presentation o. patients with conversion disorder. $cad
'merg Med. 5e- !HH52"2$:!20%#. 9?edline:.
!0. 5ord C@/ 5ol*s +G. Conversion disorders: an overview. %sychosomatics. ?ay !H852E"5$:#7!%4/ #80%
#. 9?edline:.
!!. Glic* <F/ (or*man <P/ Gau.-er, 7@. 7uspected conversion disorder: .oreseea-le ris*s and avoida-le
errors. $cad 'merg Med. Jov 20007"!!$:!272%7. 9?edline:.
!2. Fod,man CF. Conversion and somatiBation in pediatrics. %ediatr *ev. Ran !HH5!E"!$:2H%
#4. 9?edline:.
!#. Ment +6/ <omasson M/ Coryell (. Course and outcome o. conversion and somatiBation disorders. 6
.our%year .ollow%up. %sychosomatics. ?ar%6pr !HH5#E"2$:!#8%44. 9?edline:.
!4. Mroen*e M. 3..icacy o. treatment .or somato.orm disorders: a review o. randomiBed controlled
trials. %sychosom Med. +ec 2007EH"H$:88!%8. 9?edline:.
!5. 'loyd GG. 6cute -ehaviour distur-ances. / Neurol Neurosurg %sychiatry. Jov !HH#5E"!!$:!!4H%
5E. 9?edline:.
!E. ?ace CR. Fysterical conversion. ;: 6 history. 4r / %sychiatry. 7ep !HH2!E!:#EH%77. 9?edline:.
!7. ?ai 5?. SFysteriaS in clinical neurolo,y. 1an / Neurol #ci. ?ay !HH522"2$:!0!%!0. 9?edline:.
!8. ?cCahill ?3. 7omato.orm and related disorders: delivery o. dia,nosis as .irst step. $m &am
%hysician. Rul !HH552"!$:!H#%204. 9?edline:.
!H. 7chwin,enschuh P/ Pont%7unyer C/ 7urtees I/ et al. Psycho,enic movement disorders in children: 6
report o. !5 cases and a review o. the literature. Mov "isord. 6u, 2H 20089?edline:.
20. 7harma P/ Chaturvedi 7M. Conversion disorder revisited. $cta %sychiatr #cand. Oct !HH5H2"4$:#0!%
4. 9?edline:.
31
2!. 7horter 3. <he -orderland -etween neurolo,y and history. Conversion reactions. Neurol
1lin. ?ay !HH5!#"2$:22H%#H. 9?edline:.
22. 7olvason F2/ Farris 2/ Qei.ert P/ et al. Psycholo,ical versus -iolo,ical clinical interpretation: a patient
with prion disease. $m / %sychiatry. 6pr 2002!5H"4$:528%#7. 9?edline:.
2#. 7peed R. 2ehavioral mana,ement o. conversion disorder: retrospective study. $rch %hys Med
*eha0il. 5e- !HHE77"2$:!47%54. 9?edline:.
24. 7tone R/ 7myth I/ Carson 6/ et al. 7ystematic review o. misdia,nosis o. conversion symptoms and
ShysteriaS. 4M/. Oct 2H 2005##!"752#$:H8H. 9?edline:.
25. <easell I(/ 7hapiro 6P. ?isdia,nosis o. conversion disorders. $m / %hys Med
*eha0il. ?ar 20028!"#$:2#E%40. 9?edline:.
2E. <o-iano P7/ (an, F3/ ?cCausland R2/ et al. 6 case o. conversion disorder presentin, as a severe
acute stro*e. / 'merg Med. 6pr 200E#0"#$:28#%E. 9?edline:.
Ke"8ords
conversion disorder/ conversion reactions/ hysteria/ depression/ somato.orm disorder/ psychiatric condition/
psycholo,ical con.lict/ psycholo,ical need/ paralysis/ sensory distur-ances/ pseudoseiBures/ involuntary
movements/ maladaptive response to stress/ psychosocial stress/ or,anic -rain disorder/ la -elle indi..Urence/
opto*inetic nysta,mus/ monocular diplopia/ triplopia/ .ield de.ects/ tunnel vision/ -ilateral -lindness/ astasia%
a-asia
3ontri1utor )nformation and Disclosures
2ut!or
Seth Powsner, %D, Pro.essor o. Psychiatry and 3mer,ency ?edicine/ Tale Lniversity 7chool o. ?edicine
?edical +irector/ Crisis ;ntervention Lnit/ 7ection o. 3mer,ency ?edicine/ Tale%Jew Faven Fospital
7eth Powsner/ ?+ is a mem-er o. the .ollowin, medical societies: 6cademy o. Psychosomatic ?edicine/
6merican ?edical 6ssociation/ 6merican Psychiatric 6ssociation/ and 7i,ma Pi
+isclosure: Jothin, to disclose
3oaut!or
Susan Dufel, %D, A$(P, Pro,ram +irector/ 6ssociate Pro.essor/ +epartment o. <raumatolo,y and
3mer,ency ?edicine/ +ivision o. 3mer,ency ?edicine/ Lniversity o. Connecticut 7chool o. ?edicine
7usan +u.el/ ?+/ 56C3P is a mem-er o. the .ollowin, medical societies: 6merican Colle,e o. 3mer,ency
Physicians and 7ociety .or 6cademic 3mer,ency ?edicine
+isclosure: Jothin, to disclose
Medical 7ditor
7effrey *lenn 8owman, %D, %S, Consultin, 7ta../ Fi,h.ield ?I;/ Colum-us/ Ohio
+isclosure: Jothin, to disclose
,!armac" 7ditor
32
rancisco "alavera, PharmD, PhD, 7enior Pharmacy 3ditor/ e?edicine
+isclosure: Jothin, to disclose
Managing 7ditor
Robert 9arwood, %D, %P9, A$(P, AA(%, Pro,ram +irector/ +epartment o. 3mer,ency ?edicine/
6dvocate Christ ?edical Center 6ssistant Pro.essor/ +epartment o. 3mer,ency ?edicine/ Lniversity o. ;llinois
at Chica,o Colle,e o. ?edicine
Io-ert Farwood/ ?+/ ?PF/ 56C3P/ 5663? is a mem-er o. the .ollowin, medical societies: 6merican
6cademy o. 3mer,ency ?edicine/ 6merican Colle,e o. 3mer,ency Physicians/ 6merican ?edical 6ssociation/
Council o. 3mer,ency ?edicine Iesidency +irectors/ Phi 2eta Mappa/ and 7ociety .or 6cademic 3mer,ency
?edicine
+isclosure: Jothin, to disclose
3M7 7ditor
7ohn D 9alamka, %D, %S, 6ssociate Pro.essor o. ?edicine/ Farvard ?edical 7chool/ 2eth ;srael +eaconess
?edical Center Chie. ;n.ormation O..icer/ CareGroup Fealthcare 7ystem and Farvard ?edical 7chool
6ttendin, Physician/ +ivision o. 3mer,ency ?edicine/ 2eth ;srael +eaconess ?edical Center
Rohn + Falam*a/ ?+/ ?7 is a mem-er o. the .ollowin, medical societies: 6merican Colle,e o. 3mer,ency
Physicians/ 6merican ?edical ;n.ormatics 6ssociation/ Phi 2eta Mappa/ and 7ociety .or 6cademic 3mer,ency
?edicine
+isclosure: Jothin, to disclose
3!ief 7ditor
8arry ( 8renner, %D, PhD, A$(P, Pro.essor o. 3mer,ency ?edicine/ Pro.essor o. ;nternal ?edicine/
Pro,ram +irector/ Lniversity Fospitals/ Case (estern Ieserve 7chool o. ?edicine
2arry 3 2renner/ ?+/ Ph+/ 56C3P is a mem-er o. the .ollowin, medical societies: 6lpha Ome,a 6lpha/
6merican 6cademy o. 3mer,ency ?edicine/ 6merican Colle,e o. Chest Physicians/ 6merican Colle,e o.
3mer,ency Physicians/ 6merican Colle,e o. Physicians/ 6merican Feart 6ssociation/ 6merican <horacic
7ociety/ 6r*ansas ?edical 7ociety/ Jew Tor* 6cademy o. ?edicine/ Jew Tor* 6cademy o. 7ciences/ and
7ociety .or 6cademic 3mer,ency ?edicine
+isclosure: Jothin, to disclose
& !HH4% 200H -y ?edscape.
6ll Ii,hts Ieserved
"http://www.medscape.com/pu-lic/copyri,ht$
(1963). Archives of General Psychiatry. VI, 1962: Contemporary Conversion Reactions. Frederick J. Ziegler and John B. Imboden.
Pp. 279-287.. Psychoanal Q., 32:294-295.
(1963). Psychoanalytic Quarterly, 32:294-295
Archives of General Psychiatry. VI, 1962: Contemporary Conversion
Reactions. Frederick J. Ziegler and John B. Imboden. Pp. 279-287.
33
The authors examine the three elements of psychodynamic models that purportedly
explain the phenomenon of conversion: defense against anxiety, transmutation of energy,
and symbolic expression of confict. They discuss what they believe to be serious scientifc
objections to all three. Then having divorced themselves particularly from libido theory, they
present their own views: that a patient with a conversion reaction is enacting the role of a
person with organic illness, a phenomenon limited to motor and sensory systems. Other
contributing factors are the patients ideas about physical illness, identifcation with
ambivalently regarded objects, and the suitability of symptoms for symbolic representation.
!"childer once expressed his impression that motor and sensory
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appeared. It is illegal to copy, distribute or circulate it in any form whatsoever.
- 294 -
conversion reactions were modeled on organic illnesses in childhood, but he did not
dispense with the economic aspects in his formulations. #$d.%&
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appeared. It is illegal to copy, distribute or circulate it in any form whatsoever.
- 295 -
Article Citation [Who Cited This?]
/1:!30 &rchives of @eneral #sychiatry -,, 1:!2 'sychoanal 5., 3272:4+2:5
;his articl is !art #$ th su!!l"nt: %ntrnati#nal -#city #n 5rain an' 5ha,i#ur: 2n' %ntrnati#nal
C#n*rss #n 5rain an' 5ha,i#ur
P#str !rsntati#n
C#n,rsi#n !su'#'"ntia in an l'rly su:@ct
;aios ,eritogiannis( 2rgiro9)rene ,appas( /p"ros <afiris( Dimitrios ,appas an' ;enetsanos
Mavreas
D!art"nt #$ Psychiatry( +ni,rsity J#s!ital #$ %#annina( 7rc
c#rrs!#n'in* auth#r "ail
from %ntrnati#nal -#city #n 5rain an' 5ha,i#ur: 2n' %ntrnati#nal C#n*rss #n 5rain an' 5ha,i#ur
;hssal#ni2i( 7rc. 07K20 9#,":r 2005
Annals of General Psychiatry 2006( 5(-u!!l 0)=-285'#i:00.0086L0744-859M-5--0--285
Pu:lish': 28 D:ruary 2006
*ac+ground
D4 cass #$ c#n,rsi#n !su'#'"ntia in #l'r !#!l ha, :n r!#rt'. ;h tr" is us' t#
'scri: a syn'r#" #$ c#*niti, i"!air"nt( r*rssi#n an' !hysical '!n'ncy 4ith#ut ,i'nc
$#r an #r*anic '"ntia. C#n,rsi#n !su'#'"ntia raiss i"!#rtant 'ia*n#stic an' thra!utic
issus.
Materials and met!ods
34
) !rsnt a cas #$ a 73-yar #l' "al 4ith sy"!t#"at#l#*y c#"!ati:l 4ith c#n,rsi#n
!su'#'"ntia. Di$$rntial 'ia*n#sis an' thra!utic intr,nti#ns ar 'iscuss'.
:esults
;h !atint 4as a'"itt' t# #ur h#s!ital !rsntin* c#*niti, 'clin #$ a ra!i' #nst an' !r#*rss in
20 'ays ti". 1*itati#n an' :ursts #$ an*r a*ainst his 4i$ charactri>' his :ha,i#r. Durin* th
!ast siB yars h ha' :n rci,in* anti'!rssant "'icati#n. 8cnt C; scan #$ th :rain 4as
n#r"al an' th sc#r in &&-< (&ini &ntal -tat <Ba"inati#n)( siB "#nths a*# 4as 27L30. Durin* his
h#s!itali>ati#n n# a!!arnt '!rssi, sy"!t#"s 4r 'tct'( :ut th !r$#r"anc #$ &&-<
r,al' a sc#r #$ 0L30 an' !##r c##!rati#n. ;h !atint rci,' "irta>a!in( at a '#s #$ 60
"*L'ay. J 2!t :in* a**rssi, t#4ar's his 4i$( #n 4h#" h 4as '!n'nt an' s#"ti"s h
4as 4an'rin* in th h#s!ital( :in* una:l t# $in' his 4ay t# th 4ar'. ;h in$#r"ati#n a:#ut his
!r"#r:i' !rs#nality su**st' a stu::#rn !rs#n charactri>' :y !r$cti#nistic traits an'
s#"atisin* :ha,i#r. ;h ra!i' #nst #$ th sy"!t#"s #$ '"ntia an' th clinical #:sr,ati#n #$ this
!atint su**st' th 'ia*n#sis #$ c#n,rsi#n !su'#'"ntia. J 4as 'ischar*' a$tr 35 'ays. 9#
i"!r#,"nt #$ his "ntal stat 4as #:sr,'.
Discussion
;h inci'nc #$ c#n,rsi#n !su'#'"ntia is n#t 2n#4n. %t is !#ssi:l that "any cass *#
unrc#*ni>' an' *t a 'ia*n#sis #$ !su'#'"ntia 'u t# '!rssi#n. ;his ntity has als# :n
r!#rt' in y#un*r !atints. )hn !rsnt in #l'r su:@cts it rAuirs car$ul assss"nt an' "ay
: 'ia*n#s' #nly in th a:snc #$ #r*anic '"ntia #r '!rssi#n. %n s#" cass th 'ia*n#sis is
c#n$ir"' #nly :y l#n*-tr" $#ll#4 u!.
:eferences
1. &c <,#y JP( )lls C<: 3ase studies in neurops"c!iatr" ))= conversion pseudodementia.
J Clin Psychiatry 0979( 4>=447-449. Pu:&' 1:stract
8turn t# tBt
2. J!!l J: 3onversion pseudodementia in older people= a descriptive case studies.
Int J Geriatr Psychiatry 2004( 1'=960-967. Pu:&' 1:stract N Pu:lishr Dull ;Bt
8turn t# tBt
3. .i:rini P( Da*lia .( -al,i D: 5!at is t!e incidence of conversion pseudodementia?
Br J Psychiatry 0993( 12=024-026. Pu:&' 1:stract
8turn t# tBt
4. Pa'#ani )( D .# D: /evere and persistent regressive 1e!aviour in t!ree elderl"
su1@ects 8it!out cognitive decline.
Int J Geriatr Psychiatry 2000( 15=70-74. Pu:&' 1:stract N Pu:lishr Dull ;Bt
8turn t# tBt
Iesearch 6rticle
Severe and persistent re!ressive behaviour in three elderly sub:ects without co!nitive decline
(. Padoani
0 ;
/ +. +e 'eo
0 4 <
0
Psycho,eriatric 7ervice/ Lniversity o. Padua/ ;taly
4
6ustralian ;nstitute .or 7uicide Iesearch and Prevention/ Gri..ith Lniversity/ 6ustralia
<
;ICC7/ 2rescia/ ;taly
V
Correspondence to (. Padoani/ 7erviBio di Psico,eriatria/ via @endramini 7/ #5!#7 Padova/ ;taly.
35
Keywords
co,nitive impairment dependency elderly pseudodementia re,ressive -ehaviour
Abstract
<he appearance o. re,ressive -ehaviours in the elderly is relatively common. 6mon, these re,ressive attitudes/ there
is a relatively hi,h .re4uency o. situations which mimic dementia in the a-sence o. demonstra-le or,anic alterations
that 0usti.y the presence o. a neurode,enerative pro.ile. <hese ,enerally stem .rom a primary psychiatric disorder and
are re.erred to as pseudodementia . 6ll these conditions/ which are ,enerally accompanied -y a mar*ed increase in
dependency on the environment/ are distin,uished -y the presence o. co,nitive impairment and -ehavioural traits
typical o. dementia -ut which are .ully reversi-le on treatment o. the primary psychiatric disorder. Fere we descri-e
three cases/ characteriBed -y their stri*in, discrepancy -etween clinical pro.ile/ with pronounced -ehavioural
alterations similar to dementia%related conduct disorders/ culminatin, in almost complete dependency on the
environment/ and almost sta-ly intact co,nitive per.ormance "assessed throu,h the ??73$/ over a mean o-servation
period o. approAimately .ive years. Copyri,ht & 2000 Rohn (iley ) 7ons/ 'td.
$onversion Disorder
by *aria Corows2i, *&
"efinition P 3auses P <is2 8actors P $ymptoms P "iagnosis P Treatment P #revention
?n ?spaQol /$panish -ersion0

Definition
3onversion disorder is a neurological disorder in which physical symptoms are unconsciously
caused by a stressful or traumatic event &n example of this is a person who loses his voice
following a situation in which he was afraid to spea2 3onversion disorder is one of a group of
psychological disorders called somatoform disorders
$omatoform disorders are psychological disorders which are characterized by physical
symptoms that have no apparent physical cause Ahile potentially difficult to diagnose,
conversion disorder is readily treatable 3ontact your doctor if you thin2 you may have this
disorder

Causes
The direct cause of conversion disorder is usually experiencing a very stressful or traumatic
event The disorder can be considered the way someone copes, or as a psychological expression
of the event "epression and other psychological disorders are commonly seen in patients with
conversion disorder

Risk Factors
3!
& ris2 factor is something that increases your chance of getting a disease or condition
3onversion disorder may affect people at any age Ahile some studies have suggested that
conversion disorder occurs more freDuently in women, it can affect both men and women
3onversion disorders occur more commonly in rural areas, among individuals with fewer years
of education and of lower socioeconomic status
?veryone who develops conversion disorder was exposed to a traumatic event .owever, there
are other factors that may increase the li2elihood of developing the disorder, including7
& previous history of personality or psychological disease
#hysical or sexual abuse, particularly in children
8amily members with either conversion disorder or chronic illness
3o+existing psychiatric conditions such as depression or anxiety
3o+existing personality disorders, such as histrionic, passive+dependent, or passive+
aggressive personality disorder

Symptoms
,t is important to understand that the symptoms of conversion disorder are involuntary, that is,
the person does not consciously act out, or pretend that they have the symptoms & hallmar2 of
these symptoms is their lac2 of connection to any 2nown organic medical diagnoses $ome of the
most common symptoms include7
,mpaired coordination and balance
#aralysis of an arm or leg
%oss of sensation in a part of the body
%oss of a sense, such as blindness or deafness
"ifficulty swallowing or a sensation of a lump in the throat
$ensory symptoms, such asF
%oss of sense of pain
Tingling or crawling sensations
Nervous System
36
&n emotional event may trigger physical symptoms, sometimes through peripheral nerves
/yellow0
6 2//7 Nucleus Medical Art, 2nc.
To be diagnosed with conversion disorder you must have at least one symptom, but you may also
have many The appearance of symptoms is lin2ed to the stressful event, and typically occur
suddenly /eg, seeing something extremely unpleasant and suddenly going blind0 ,f you
experience any of these symptoms, do not assume it is due to conversion disorder These
symptoms may be caused by other, less serious health conditions ,f you experience any one of
them, see your physician

Diagnosis
"iagnosis of conversion disorder may be difficult initially because physical symptoms are most
often caused by a physical disorder ,t is important for the physician to consider a physical cause
for the symptoms carefully Oour doctor will as2 about your symptoms and medical history, and
perform a complete physical exam #atients will often be as2ed to undergo the following testing
to rule out an underlying disease
%aboratory testing to rule out hypoglycemia or hyperglycemia, 2idney failure, or drug+
related causes
,maging studies, such as chest x+rays or 3T scans
35
?lectrocardiogram /?3@, ?L@0 Ra test that records heart activity by measuring
electrical currents through the heart muscle
$pinal fluid examination to chec2 for neurological causes
,f no physical cause is detected, the patient may either be referred to a neurologist or for a
psychiatric consultation

Treatment
,n some cases, patients may begin to recover spontaneously &fter physical causes for the
symptoms have been ruled out, patients may begin to feel better and symptoms may begin to
fade ,n some cases, patients may need assistance in recovering from their symptoms Treatment
options may include the following7
3ounseling and psychotherapyR"iscussing the stressful event with a counselor may help
you cope with the underlying cause of the physical symptoms 3ontinued wor2 to learn
how to deal with stressors throughout life will also be important, as about 25G of patients
with these disorders often have future episodes
#harmacological therapyR,n some cases, antidepressants may be used to speed recovery
$tudies have shown that antidepressants may be helpful for patients with conversion
disorder
Physical and2or =ccupational "herapy
#atients may reDuire therapy to overcome disuse of a limb, for example, and to relearn normal
behaviors

Prevention
There are no guidelines to preventing conversion disorder because it occurs after a specific,
traumatic event .owever7
#sychological disorders can carry a feeling of being stigmatized ,t is important that you
do not let this prevent you from see2ing treatment
$omatoform disorders are very common, and treatment is very effective "o not hesitate
to call your doctor if you have symptoms suggestive of conversion disorder
<?$)B<3?$7
&merican #sychiatric )rganization
http799wwwpsychorg
3:
&merican #sychological )rganization
http799wwwapaorg
3&4&",&4 <?$)B<3?$7
3anadian #sychiatric &ssociation
http799wwwcpa+apcorg
3anadian #sychological &ssociation
http799wwwcpaca9cpasite9homeasp
./..NC.S!
3onversion disorder *edline#lus B$ 4ational %ibrary of *edicine and the 4ational ,nstitutes
of .ealth &vailable at7 http799wwwnlmnih &ccessed (uly 5, 2''5
3onversion disorder The *erc2 *anual of "iagnosis and Therapy website &vailable at7
http799wwwmerc2c &ccessed (uly 5, 2''5
"ufel $ 3onversion disorder ?*edicine website &vailable at7
http799wwwemedicinecom9emerg9topic112htm9 &ccessed (uly 5, 2''5
.eller * 3onversion disorder ,n7 ,erri8s Clinical Ad.isor1 2nstant 3ia)nosis and 4reatment
5th ed #hiladelophia, #&7 *osbyF 2''!
%ast reviewed 4ovember 2''5 by Theodor C <ais, *"
%ast Bpdated7 119169'5
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4'



0ear 7 2''! P 1olume 7 45 P Issue 7 3 P 2a3e 7 1:5++2''
3ompulsive symptoms in dissociative /conversion0 disorder
Arun 4ata A3arwal
"epartment of #sychiatry, *aulana &zad *edical 3ollege and @C #ant .ospital, 4ew "elhi, ,ndia
Correspondence Address7
&run %ata &garwal
.+13, *ir "ard %ane, *&*3 3ampus, 4ew "elhi 11'''2
,ndia
&bstract
&ccording to *ayer+@ross, $later and <othT$UVs classical textboo2 Clinical 9sychiatry, obsessive+compulsive
symptoms are rarely seen in hysteria The release of obsessive+compulsive symptoms is said to occur only in those
who are constitutionally predisposed ,n this context, the case of a young woman with dissociative /conversion0
disorder, who presented with compulsive symptoms, is reported ,n her case, the dissociative phenomena manifested as
compulsive symptoms without concomitant predisposing factors *anagement on the line of treatment for hysteria
promptly achieved lasting resolution of symptoms without recourse to pharmacological or non+pharmacological
treatment strategies used for obsession/s0 or compulsion/s0 The underlying mechanism/s0 are discussed
(ow to cite this article!
&garwal &% 3ompulsive symptoms in dissociative /conversion0 disorder,ndian ( #sychiatry 2''!F4571:5+2''
(ow to cite this 54!
&garwal &% 3ompulsive symptoms in dissociative /conversion0 disorder ,ndian ( #sychiatry =serial online> 2''!
=cited 2'': 8eb 1: >F4571:5+2''
Available from! http799wwwindian1psychiatryorg9textaspK2''!9459391:5931556
8ull Text
41
,ntroduction
&ccording to conventional clinical teaching, obsessive+ compulsive symptoms /)3$0 are rarely seen in the
dissociative /conversion0 disorder /"3"0 This fact is also reflected in the statement mentioned in a classical textboo27
;compulsive symptoms are rare in hysterical reactions;, which further adds that )3$ are released only in those who
are constitutionally predisposed and not otherwise=1> ,n contrast, "3" can occur even without a predisposing
medical, neurological or psychiatric disorder=2>
The robustness of the above+mentioned clinical wisdom is borne out by the sparseness of published literature in this
area Lamins2y and $lavney have published two reports dealing with prominent )3$ and obsessional traits in patients
with the briDuet syndrome=3>,=4> and hysterical personality=4> Cieniec2a and $ulestrows2a reported the case of a child
whose compulsive motor acts were hysterical reactions caused by an insurmountable fear of school=5> <oss and
&nderson observed ego+alien )3$+li2e symptoms in many patients suffering with multiple personality disorder=!> 4o
,ndian data on compulsive symptoms in hysterical reactions have been published )ne such case is reported below and
the probable underlying mechanisms have been discussed
The 3ase
*s L, a 1:+year+old matriculate and housewife of rural origin from a low socioeconomic status and married for 1'
months, was brought by her spouse and in+laws, with problems of 3 days; duration The history revealed that within a
month of marriage L began refusing sex ,n the ensuing 3 months she often Duarrelled after sex and even impulsively
attempted suicide thrice
"uring the next 4 months, L;s unwillingness for sex continued, along with recurrent amnesia of marriage &dditionally,
she would be possessed, up to 5 times a day, by the ;spirit; of a young female /of *, who, though a postgraduate, had
committed suicide because of failure in love0 The spirit of * claimed7 ;, had entered L 3 days prior to her =ie L;s>
marriage Therefore marriage was with me, and L, being unmarried, should not be troubled =ie sexually> by the
husband; Ahen faith+healing did not give lasting relief, village elders reorganized their marriage rites on 3+4
occasions, but each time the improvement, including permitting sex, was limited to 2+3 wee2s only Thereafter, L
again became Duarrelsome, gave suicide threats and demanded to be sent to her natal place, where she remained well
for a month .er reluctance for sex persisted even after returning from her natal place and during the following one
month she had four pseudoseizures after sex
*s L again had sex with her husband, few days after the last pseudoseizure ,mmediately thereafter, she developed the
symptoms of repeated hand+washing and bathing, not touching anything besides not eating, drin2ing or tal2ing These
symptoms resembled her husband;s obsession regarding contamination /by dirt0 and compulsive hand+washing, which
he had developed a few months after their engagement, but which he had completely remitted within 3 months of
treatment with fluoxetine prescribed by a psychiatrist elsewhere $ubseDuently, he had remained well
The appearance of similar symptoms in L, immediately following sex, prompted speculation among filial relatives that
the husband;s past illness may have been /sexually0 contagious, and that she may also need similar medical treatment
42
$o L was brought directly to a psychiatrist, the first physician to be contacted after marriage, within 3 days of the onset
of these symptoms
&t the time of consultation, the results of L;s physical examination were within normal limits and her mental state
revealed mutism, anxiety and compulsive hand+washing ,n view of her :+month history preceding the consultation,
for seemingly compulsive behaviour, L was diagnosed and treated as a case of mixed dissociative /conversion0
disorder /8 4460, according to the ,3"+1'
The presenting symptoms ameliorated within 24 hours of admission /due to the change of environment0 as a result of
an initial transfusion of a bottle of dextrose saline /used as psychological symbol of medical treatment0, and
encouragement for her to express herself $imultaneously, the family members; cooperation was solicited, their
misconceptions regarding the contagious nature of illness dispelled, their other anxieties allayed and psycho+education
imparted
<econstruction of the bac2ground
,nformation gathered primarily from L, and supplemented by her husband and in+laws, suggested that premorbidly L
had prominent histrionic traits not amounting to a personality disorder
L was engaged by her parents at the age of 1! years, on the personal initiative of the would+be bridegroom /ie her
current husband0, much against her wish ,n spite of the groom;s desire for early marriage, she had delayed it for more
than 2 years
& few months before engagement, L had felt severely disappointed on /forced0 discontinuation of her studies /beyond
matriculation0 as per the village norm for girls of her age "uring this time, her brother+in+law /ie her sister;s
husband0 was Duite supportive of her and gradually became physically intimate with her Their clandestine sexual
relationship continued, sporadically, for long even after her engagement till she terminated it after much
procrastination, and consented for marriage .owever, her emotional turmoil continued on account of unresolved grief
over the loss of a relationship and guilt of premarital sexual relations with another man
The consummation of marriage further compounded her emotional dissonance, which she could not contain despite her
best efforts $he soon developed mar2ed irritability and severe disinclination towards sex .er husband, although Duite
supportive, bore the ma1or brunt, for none of his fault, which further burdened her Therefore, after brief period/s0 of
sexual abstinence, she reluctantly but repeatedly gave in to her husband;s urgings for sex ,n the ensuing emotional
upheaval, however, the afore+mentioned problem behaviours appeared one after the other
,mmediately following sex, the last time before presentation, L was suddenly afflicted by a Dueer thought that she was
contaminated by ;semen;, and that she was even spreading the contamination through her hands $he was unable to
control these thoughts, which started to increase in her husband;s presence .er thoughts were her so uncontrollable,
senseless, repetitive and distressing that she had to repeatedly wash her hands, bathe or change her clothesF she could
not touch anything, as any touched ob1ect also had to be washed repeatedly *oreover, she could not eat or drin2
anything, as any touched food or drin2 also had to be discarded To ma2e matters worse, the nature of her thoughts
precluded their sharing, and this led to her mutism
)nce L had emotionally unburdened herself, only the conscious conflicts were addressed in individual and con1oint
therapy sessions, along with efforts to augment her coping s2ills $he gradually came to terms with her marriage, was
43
able to ad1ust well with her husband, and continued to be asymptomatic till : months of follow+up, after which further
visits were discontinued on reDuest
"iscussion
-iewed socioculturally,=2> the patient;s distress signals did communicate her cry for help, in addition to achieving
temporary avoidance of the distressing situation /ie marital sex0 .er spouse and in+laws also recognized her cries for
help, however, not as a ;medical; problem but on the lines of a shared sociocultural belief system, which is further
borne out by the husband;s statement7 ;Ae followed the advice rendered by the family and village elders, priests, o1has
and fa2irs, etc for her EotherE problems for almost : months continuously but we brought =her> to a medical doctor =a
psychiatrist> when she developed an actual illness, similar to my earlier disease Ae suspect that she got it from me;
-iewed psycho+dynamically,=2> the ongoing conflicts unconsciously reactivated a /related0 latent intrapsychic conflict,
necessitating deployment of symptom+forming defences, so as to lessen the intrapsychic anxiety .owever, the
presence of /conscious0 anxiety, in spite of these defences, in such patients is in accordance with the literature=6>,=5>
The presence of obvious elements of personal significance /of the recent past0 in the patient;s symptomatology is also
in accordance with the literature=1>
The most valid definition of )3$ is said to include the following three elements7 intrusiveness, repetitiveness, and
groups of resistance, distress, irrationality and difficulty in dismissing=:> The presenting complaint had all these three
elements and thus Dualified as an )3$
$till, in this case, the manner in which these )3$ suddenly appeared, in the absence of premorbid traits of
obsessionality, following a recurring precipitant /sex with husband0, for brief duration /4 days0, their superficial
resemblance with the husband;s past illness /conversion model0, their exacerbation in the husband;s presence and their
rapid resolution without specific pharmacological or behavioural intervention directed at them suggests that these )3$
were generated not by the classical mechanisms of a true obsessional but by the same mechanisms which had brought
about other "3" <oss and &nderson have also argued that auto+hypnotic "3" patients are capable of exhibiting
diverse pheno+menology of different diagnoses and, in such cases, all the diverse presentations should be viewed as
facets of a single polysymtomatic "3" rather than comorbid diagnoses=!>
#ractice point
"espite the avowed rarity of )3$ in "3", this case illustrates the importance of underlying diagnosis even when clear
)3$ are present The history of illness and the context of symptoms provide important clues to diagnosis The )3$ in
these patients respond to the same treatment strategies as used in the management of "3"=:>
<eferences
1 #ersonality deviations and neurotic reactions ,n7 $later ?, <oth * /eds0 Mayer-:ross,
Slater & &oth-s clinical 9sychiatry. 3rd ed %ondon7 Cailliere Tindall 1:!:71'3+36
2 @uggenheim 8@ $omatoform disorders ,n7 $adoc2 C(, $adoc2 -& /eds0 Ka9lan &
Sadoc+-s com9rehensi.e textoo+ of 9sychiatry. 6th ed #hiladelphia7 %ipincott Ailliams J
Ail2insF 2'''715'5+:
44
3 Lamins2y *(, $lavney #< *ethodology and personality in briDuet;s syndrome7 &
reappraisal Am % 'sychiatry 1:6!F1337 55+5
4 Lamins2y *(, $lavney #< .ysterical and obsessional features in patients with briDuet;s
syndrome /somatization disorder0 'sychol Med 1:53F137111+2'
5 Cieniec2a &, $ulestrows2a . 3ompulsive motor acts as a hysterical reaction caused by
insurmountable fear of school 'sychiat 'ols+a 1:52F1!72'1+3
! <oss 3&, &nderson @ #henomenological overlap of multiple personality disorder and
obsessive+compulsive disorder ( Ner. Ment 3is 1:55F16!72:5+:
6 8oulds @&, Cedford & The relationship between anxiety, depression and the neuroses (r
% 'sychiatry 1:6!F1257 1!!+5
5 Latoch -, (hingan .#, $axena $ %evel of anxiety and dissociation in patients with
conversion and dissociative disorders 2ndian % 'sychiatry 1::4F3!7!6+:
: Lhanna $, Laliaperumal B@, 3hannabasvanna $* ?xplorations of obsessive+compulsive
phenomenon7 & preliminary investigation 'sycho9athol 1::2F25724:+53
emedicine.medscape.com
&'icin -!cialtis I Psychiatry I Psych#s#"atic
Conversion Disorders
Scott A %arshall, %D, 7enior 5ellow/ Jeurocritical Care/ Rohns Fop*ins Lniversity 7chool o. ?edicine/ +ivision o.
Jeurosciences Critical Care +epartment o. Jeurolo,y/ Lni.ormed 7ervices Lniversity o. the Fealth 7ciences/ 2ethesda/
?aryland.
%ark ( >andau, %D, Jeurolo,y Pro,ram +irector/ Jational Capital Consortium/ 6ssociate Pro.essor/ Lni.ormed 7ervices
Lniversity o. the Fealth 7cience/ Jeurophysiolo,y 7ection/ +epartment o. Jeurolo,y/ (alter Ieed 6rmy ?edical Center
$rai! * $arroll, D=, 7ta.. Jeurolo,ist/ Fead o. Clinical Jeurophysiolo,y 7ection/ Javal ?edical Center Portsmouth
8ryan Schwieters, %D, Consultin, Physician/ 7chwieters ?edical P''C and 7t Roseph8s Fospital
Lpdated: +ec 22/ 2008
)ntroduction
*ac+ground
Conversion disorder/ as stated in the "iagnostic and #tatistical Manual of Mental "isorders, &ourth 'dition,
(e)t *evision +"#M,-.,(*!, involves symptoms or de.icits a..ectin, voluntary motor or sensory .unction that
su,,est a neurolo,ic or other ,eneral medical condition. Tet/ .ollowin, a thorou,h evaluation/ which includes a
detailed neurolo,ic eAamination and appropriate la-oratory and radio,raphic dia,nostic tests/ no neurolo,ic
eAplanation eAists .or the symptoms/ or the eAamination .indin,s are inconsistent with the complaint. ;n other
words/ symptoms o. an or,anic medical disorder or distur-ance in normal neurolo,ic .unctionin, eAist that are
not re.era-le to an or,anic medical or neurolo,ic cause.
!

Common eAamples o. conversion symptoms include -lindness/ diplopia/ paralysis/ dystonia/ psycho,enic
nonepileptic seiBures "PJ37$/ anesthesia/ aphonia/ amnesia/ dementia/ unresponsiveness/ swallowin,
di..iculties/ motor tics/ hallucinations/ pseudocyesis and di..iculty wal*in,.
Ieports o. less common mani.estations o. conversion disorder a-ound in the literature and include
camptocormia/ clenched .ist syndrome/ recum-ent ,ait/ odd vocaliBations/ and pseudo .orei,n accent
syndrome.
2/ #/ 4/ 5/ E

45
?ultiple symptoms su,,est a somatiBation disorder. Conversion disorder is a type o. somato.orm disorder
where physical symptoms or si,ns are present that cannot -e eAplained -y a medical condition. @ery
importantly/ unli*e .actitious disorders and malin,erin,/ the symptoms o. somato.orm disorders are not
intentional or under conscious control o. the patient.
$ase study
6 youn, woman>s .amily -rin,s her to the hospital and she presents with a chie. complaint o. Wspells.X ;t seems
that over the past several wee*s/ the patient has su..ered .rom attac*s o. -ilateral arm 0er*in,/ .ollowed -y
-ilateral le, 0er*in, a.ter she lowers hersel. to the .loor. O.ten/ her head sha*es violently side to side and her
eyes are seen to Sroll -ac* in her headS .ollowed -y .orced eye closure. <hese incidents .ollow episodes o.
emotional out-ursts/ and the patient is .ortunately a-le to warn others that W;>m a-out to have a seiBureYX 6.ter
hearin, this/ her .amily ,ra-s the patient and places her in a chair or on the ,round until the spell is over/ which
sometimes can waA and wane .or 20%#0 minutes with varyin, intensity.
<hese spells are not accompanied -y loss o. -ladder or -owel continence/ -ut o.ten the patient -ites the tip o.
her ton,ue and *ic*s over ta-les or stri*es .amily mem-ers durin, an episode. <his most recent spell occurred
while the patient was drivin, her car/ in which she warned o. an impendin, seiBure and pulled the car to the
shoulder 0ust -e.ore losin, consciousness her spell was much more intense than she has had in the past.
7he has no si,ni.icant past medical history and ta*es no medications. 7he reports a past history o. childhood
seAual a-use .rom a paternal uncle several years a,o. On eAam/ her vitals si,ns are normal and her neurolo,ic
evaluation is without si,ni.icant .indin,s. 7he is not orthostatic. 'a-oratory wor*%up/ includin, urine toAin
screen/ is ne,ative.
,at!op!"siolog"
Conversion symptoms su,,est a physical disorder -ut are the result o. psycholo,ical .actors. 6ccordin, to the
psychodynamic model/ the symptoms are a conse4uence o. emotional con.lict/ with the repression o. con.lict
into the unconscious. ;n the late !880s/ 5reud and 2reuer su,,ested that hysterical symptoms resulted .rom
the intrusion o. Smemories connected to psychical traumaS into the somatic innervation. <his mind%to%-ody
process was re.erred to as conversion. Others have introduced attachment theory as a means to
understandin, conversion disorder in terms o. the free5e response and the appeasement defense -ehavior
seen in animal su-0ects.
7

<he patient has -een postulated to derive primary and secondary ,ain. (ith primary ,ain/ the symptoms allow
the patient to eApress the con.lict that has -een suppressed unconsciously. (ith secondary ,ain/ symptoms
allow the patient to avoid unpleasant situations or ,arner support .rom .riends/ .amily/ and the medical system
that would otherwise -e uno-taina-le. 6ccordin, to sociocultural theories/ the direct eApression o. emotions is
impermissi-le and somatiBation ta*es its place. ;n -ehavioral models/ conversion symptoms are viewed as a
learned maladaptive -ehavior that is rein.orced -y the environment.
<he idea that conversion disorder does not have an or,anic -asis has -ecome entrenched. Fowever/ some
evidence supports the opposite notion. 6 review o. ima,in, correlates in patients with motor and sensory
conversion symptoms is re.erenced.
8
7tudies on the natural history o. conversion disorder indicate that many
patients su-se4uently develop or are .ound to have preeAistin, neurolo,ic disease. ;n .act/ conversion
disorders may -e more .re4uently o-served in patients with a past history o. a central nervous system in0ury.
<he simultaneous occurrence o. or,anic -rain disease with conversion symptoms is also o-served/ most
4!
nota-ly in o-servation o. hi,h rates o. or,anic seiBure syndromes associated with psycho,enic nonepileptic
seiBures "PJ37$. 5amilial studies have also shown that conversion symptoms in .irst%de,ree .emale relatives
are up to !4 times ,reater than in the ,eneral population.
<hat the dia,nosis o. a conversion reaction o. disorder represents a .ailed dia,nosis o. an or,anic syndrome/
perhaps with psycho,enic overlay that o-scures eAam and other .indin,s is usually a valid concern. 6 recent
meta%analysis includin, more than !400 cases with .ollow%up over 5 years reported missed or,anic dia,nosis
rates o. less than 5C.
H
<his correlates with similar reports .or the dia,nosis o. motor neuron disease or
schiBophrenia.
!0
Past rates o. misdia,nosis were reported as considera-ly hi,her.
H

Fre-uenc"
.nited /tates
7te.ansson et al report that the annual incidence o. conversion reactions is 22 cases per !00/000 persons per
year in ?onroe County/ Jew Tor*. Fowever/ the reported rates vary widely.
!!
;n a study o. !00 consecutive
women .ollowin, a normal .ull%term pre,nancy/ ## were noted to have a past history o. conversion symptoms.
;n a study o. !00 randomly selected patients .rom a psychiatry clinic/ 24 were noted to have uneAplained
neurolo,ic symptoms. 6 report -y Carson .ound that #0C o. patients at a neurolo,y clinic had SuneAplained
symptoms.S
!2

Overall/ conversion disorder is reported to -e more common in rural populations/ in individuals with lower
socioeconomic status/ lac* o. education/ and low psycholo,ical sophistication.
!#
<he increased rate o.
conversion in patients with a past history o. seAual or physical a-use is well descri-ed.
!4/ !5

)nternational
7te.ansson et al report that the annual incidence is !! cases per !00/000 persons per year in ;celand.
!!

Mortalit"0Mor1idit"
;ndividual conversion symptoms are ,enerally sel.%limitin, and do not lead to physical chan,es or
disa-ilities. ;n the case o. PJ37/ patients may have drivin, privile,es removed -y medical
practitioners and may sel.%limit other activities due to concern over havin, a paroAysmal event. <he
symptoms related to the conversion disorder may lead to decreases in 4uality o. li.e i. they are
perceived as e,odystonic.
?or-idity is o.ten an iatro,enic mani.estation o. unnecessary dia,nostic or therapeutic interventions
aimed at esta-lishin, an or,anic dia,nosis .or the patient8s symptoms.
Patients with chronic conversion symptoms rarely may develop atrophy/ .roBen 0oints/ and contractures
.rom disuse.
/e$
Classically/ the .emale%to%male ratio is 2%!0:!.
Iecent wor* with PJ37 reports that males ma*e up approAimately 40C o. cases. <his is a departure
.rom past wor*/ where .emales made up 80C o. cases o. PJ37 in some series.
!E

Overall/ .emale%to%male ratio is varia-le/ -ut the occurrence o. conversion disorder is li*ely hi,her in
.emales overall.
2ge
46
<he typical onset is -etween the second and .ourth decades.
<he reported ran,e is .rom children to individuals in their ninth decade o. li.e.
3linical
4istor"
Conversion symptoms are those that su,,est neurolo,ic disease/ -ut no eAplanation o. these symptoms is
.ound .ollowin, physical eAamination and dia,nostic testin,. <he presentation is acute in onset and may .ollow
a psycholo,ically con.lictual situation. Conversion symptoms are seen in various clinical settin,s and include
conversion disorder somatiBation disorder a..ective disorders antisocial personality disorder alcohol or dru,
a-use or or,anic/ neurolo,ic/ or medical illnesses.
;n some situations/ an immediate precipitatin, source o. stress may -e disclosed/ such as a loss o.
employment or divorce. <he patient may have a discordant home li.e. 6 history o. seAual or physical a-use is
not uncommon and can -e seen in as many as one third to one hal. o. patients with dissociative disorder/
respectively. <here.ore/ a complete and comprehensive psychosocial history is o. vital importance. Patients
with conversion disorder are said to have a relative lac* o. concern a-out the nature or implications o. the
symptoms 5reud descri-ed this as la 0elle indifference. <his is not a help.ul dia,nostic characteristic -ecause
it is not speci.ic or sensitive .or conversion and should have no isolated role in separatin, or,anic .rom
psychiatric disease.
!0
7ystematic reviews on this su-0ect .ound the .re4uency o. this .indin, at 2!C amon,
those with a conversion disorder and 2HC amon, those with or,anic disease.
!7

+ia,nostic criteria .or conversion disorder as per the "#M,-.,(* are as .ollows:
!8

o One or more symptoms or de.icits are present that are a..ectin, voluntary motor or sensory
.unction and su,,est a neurolo,ic or other ,eneral medical condition.
o Psycholo,ical .actors are 0ud,ed to -e associated with the symptoms or de.icits -ecause the
initiation or eAacer-ation o. the symptom or de.icit is preceded -y con.licts or other stressors.
o <he symptom or de.icit is not produced intentionally or .ei,ned/ as in .actitious disorder or
malin,erin,.
o <he symptoms or de.icit cannot/ a.ter appropriate investi,ation/ -e eAplained .ully -y a
,eneral medical condition/ -y the direct e..ects o. a su-stance/ or as a culturally sanctioned
-ehavior or eAperience.
o <he symptom or de.icit causes clinically si,ni.icant distress or impairment in social/
occupational/ or other important areas o. .unctionin, or warrants medical evaluation.
o <he symptom or de.icit is not limited to pain or seAual dys.unction/ does not occur eAclusively
durin, the course o. somatiBation disorder/ and is not -etter accounted .or -y another mental
disorder.
Possi-ilities to consider when a patient presents with symptoms o. pro-a-le psycho,enic ori,in include
the .ollowin,:
o 7ymptoms are eAclusively a .unction o. somato.orm disorder/ .actitious disorder/ or
malin,erin,.
o 7ymptoms are secondary to other psychiatric etiolo,ies such as depressive disorder or
anAiety disorders.
o 7ymptoms coeAist with a physical disorder.
o <he symptoms are an unusual mani.estation o. a physical disorder.
<he "#M,-.,(* lists strict criteria .or dia,nosin, conversion disorder. Fowever/ 2 o. the listed
conditions may -e determined only -y a person with eApertise in neurolo,ic conditions/ neuroanatomy/
45
and the reco,niBed clinical patterns o. disease in correlation with the lesion location. <his is usually a
neurolo,ist. <he psychiatric assessment can di..erentiate conversion disorder .rom other somato.orm
disorders/ .actitious disorder/ and malin,erin, and can elucidate the psychodynamics that are very
important in treatment. <he neurolo,ist must reco,niBe the nonor,anic process and rule out imitators
while avoidin, potentially dan,erous dia,nostic or therapeutic interventions. <he neurolo,ist and
psychiatrist are thus prepared to dia,nose conversion disorder -est when wor*in, in concert.
!0

Patients with conversion disorder may present with hemiparesis/ paraparesis/ monoparesis/ alteration
o. consciousness/ visual loss/ seiBure li*e activity/ pseudocoma/ a-normal ,ait distur-ance/ aphonia or
dysphonia/ lac* o. coordination/ or a -iBarre movement disorder. Patients who are more medically
naZve typically have more implausi-le presentin, symptoms and vice versa. <he presentin, symptoms
depend on the cultural milieu/ the de,ree o. medical sophistication/ and the underlyin, psychiatric
issue.
Patients with conversion disorder may deny any emotional pro-lem and 4uite commonly
resist consultation with psychiatry. <here.ore/ responsi-ility lies with other medical personnel to
per.orm the initial mana,ement prior to conveyin, the dia,nosis.
,!"sical
6 .ull physical eAamination with attention to the mental status and neurolo,ic eAamination should -e per.ormed.
Certain principles are used durin, the neurolo,ic eAamination to distin,uish psycho,enic de.icits .rom
neurolo,ic ones. <he pattern o. de.icits usually does not con.orm to *nown anatomic pathways. 5or eAample/
patients who present with monoparesis do not have wea*ness in a corticospinal tract or neuropathic or
myopathic distri-ution. ;n addition/ no chan,es may -e seen in re.leAes or tone that typically would -e
eApected.
<he physician should contrast .ormal eAamination .rom .unctional o-servations. Patients who do not move a
lim- when as*ed on eAamination may -e o-served to use that lim- inadvertently while dressin, or tal*in,.
;mportantly/ one should di..erentiate ina-ility to move a lim- on command .rom spontaneous movements. <his
may imply a receptive aphasia rather than a conversion disorder. Patients who do not dorsi.leA the .oot while
seated may wal* on the heels when as*ed to do so. 6nother eAample mi,ht -e a patient who cannot stand on
one le, who may -e o-served to do so while puttin, on pants.
O-servations when the patient is unaware o. -ein, eAamined are help.ul. Patients with psycho,enic
movements may have no such movements when o-served in the waitin, room. ?ultiple eAaminations -y one
or more practitioners may disclose varia-le results. Fowever/ caution is necessary when applyin, these rules.
Jo sin,le .eature is a-solute. <he *nowled,e pertainin, to neuroanatomy and the clinical de.icits that arise
.rom certain a-normalities is not completely *nown/ thus resultin, in limitations o. the neurolo,ic eAamination.
;n addition/ patients can em-ellish on or,anic de.icits/ there-y ma*in, clinical assessment di..icult and .urther
introduction o. varia-ility -etween eAaminers.
O. concern/ older data/ most nota-ly -y 3liot 7later in !HE5/ pu-lished rates o. ##C .or patients with conversion
disorder ultimately developin, a physical illness that may account .or their symptoms.
!H
Patients with conversion
disorder not uncommonly have a comor-id medical or neurolo,ic illness. 6n eAample is the patient who eAhi-its
-oth epileptic seiBures and psycho,enic nonepileptic seiBures/ a clinical situation accountin, .or up to !0%20C
o. re.errals to epilepsy re.erral centers.
20/ 2!
6lthou,h current rates o. misdia,nosis are low/ this remains a valid
concern amon, practitioners.
H

6ssessment o. mental status durin, eAamination is paramount. <he .ollowin, mental status eAamination
eAample .ocuses only on the possi-le presentation o. a patient with conversion symptoms. ;n a clinical settin,/
4:
one would li*ely see the comor-id psychiatric presentations as well. <hese may -e hard to distin,uish and
separate .rom the conversion symptoms "e,/ hallucinations and delusions may -e a conversion symptom or
symptoms o. a psychotic disorder$.
%ental status e)amination
6ppearance % Jormal dress appropriate eye contact normal hy,iene
Gait/station % Jormal or ataAia/ some type o. psycho,enic paresis/ pseudochorea/ astasia%a-asia
pattern o. ,ait "ie/ ina-ility to wal* due to wea*ness or -alance de.icits -ut can hop on ! le, -ac* and
.orth to the -athroom$
6ttitude % 6ppropriate
2ehavior % Could -e preoccupied with symptoms or indi..erent
7peech % ?ay -e normal or have evidence o. the conversion disorder such as aphonia/ dysphonia/
ver-al tics/ stutterin,
6ttention/concentration % ?ay -e decreased due to preoccupation with symptoms or may -e normal
?emory % Jormal or impaired
Orientation % 'i*ely oriented to person/ place/ and time
?ood % Perhaps anAious a-out condition perhaps indi..erent
6..ect % ?ay -e restricted la-ile or mood incon,ruent
<hou,ht process % Could also vary .rom concrete and perseverative to normal o-sessive component
also possi-le
<hou,ht content % Jot li*ely suicidal or homicidal unless comor-id conditions present
Fallucinations % Possi-le hallucinations present "<he patient usually retains some insi,ht that these are
not real. <he conversion hallucinations o.ten involve multiple modalities 9ver-al/ tactile/ visual:.
Compared with hallucinations in psychosis that usually involve a sin,le modality/ these hallucinations
are o.ten psycholo,ically si,ni.icant 9ie/ S; heard my eA%-oy.riend8s voice tellin, me that he had made a
-i, mista*e.S:. O.ten they are ima,inative and childish in nature and o.ten presented as a story.
!#

Please note that i. the hallucinations are -etter accounted .or -y post traumatic stress disorder or
dissociative identity disorder/ a dia,nosis o. conversion disorder should not -e made.$
!#

;nsi,ht % 'imited to poor
Rud,ment % @aries .rom case to case
Other speci.ic details to help dia,nose # di..erent common conversion symptoms include the .ollowin,:
Psycho,enic hemiparesis
o Lnilateral wea*ness or hemiparesis is one manner in which the patient with conversion
disorder may present.
Classic hemiparesis represents a de.icit o. the corticospinal tract. ;n an acute lesion
o. the corticospinal tract/ a patient may demonstrate .laccidity o. the wea* lim-s/
which is associated with decreased re.leAes. ;n more chronic lesions/ the patient may
develop spasticity o. the a..ected lim-s/ hyperre.leAia/ and an eAtensor toe si,n
"positive 2a-ins*i$. <he patient with hemiparesis .rom a corticospinal tract lesion may
demonstrate wea*ness o. the eAtensor muscles to a ,reater eAtent than the .leAor
muscles and may show ,reater wea*ness distally than proAimally.
Jone o. these .indin,s would li*ely -e seen in the patient with conversion disorder. ;n
psycho,enic hemiparesis/ the muscle contractions are poorly sustained and may
wea*en a-ruptly as the patient resists the .orce eAerted -y the eAaminer. <his is .elt
clinically as a S,ive%wayS or ratchet%li*e wea*ness/ unli*e the .luid wea*ness
5'
throu,hout the ran,e o. motion usually .elt -y the eAaminer in an upper or lower
motor neuron lesion. Jote that many o. these type o. si,ns have -een shown to not
-e speci.ic .or conversion/ includin, ,ive%way wea*ness.
22

o <he Foover si,n may also -e elicited. (hen a patient in the recum-ent position .leAes the
thi,h and li.ts the le,/ the downward movement o. the contralateral le, is automatic. <he
eAaminer places a hand -eneath the heel and as*s the patient to raise the paretic le,. ;n
.ei,ned wea*ness/ no apprecia-le downward movement is evident. ;n addition/ when the
patient is as*ed to raise the normal le,/ the downward movement is appreciated .rom the
paretic le,. <his is .elt to -e a reasona-ly relia-le indication o. a possi-le conversion
disorder.
!0

o 6nother help.ul tool is eAaminin, the sternocleidomastoid muscle. Jormal contraction o. this
muscle results in the .ace rotatin, in the opposite direction. <here.ore/ the patient with
psycho,enic wea*ness may display wea*ness o. the contralateral sternocleidomastoid "ie/
wea*ness in turnin, the .ace towards the hemiparetic side$.
o Ieco,niBin, the patient with psycho,enic hemiparesis includes o-servin, the .ollowin,:
Jo side%to%side chan,es in re.leAes or tone
Give%way 4uality o. wea*ness
22

3Atensor and .leAor muscles e4ually wea*
Contralateral sternocleidomastoid wea*ness
Positive Foover si,n
2#

+i..erence -etween .ormal eAamination and ,eneral o-servations "ie inconsistency$
!0

Psycho,enic nonepileptic seiBures
o +istin,uishin, -etween a psycho,enic nonepileptic seiBure/ or pseudoseiBure/ and an
epileptic seiBure is challen,in,. <he mani.estations o. each are diverse/ and the clinical
dia,nosis rests on historical in.ormation .rom witnesses with varyin, o-servational s*ills.
7imultaneous video electroencephalo,ram "33G$ monitorin, has si,ni.icantly improved the
accuracy o. dia,nosis/ -ut this techni4ue is eApensive and not routinely availa-le.
Psycho,enic seiBures may constitute up to 20C o. all patients in an epilepsy re.erral center.
24

Please re.er to the article on Psycho,enic 7eiBures in the e?edicine Jeurolo,y section .or
more details.
o Classic clues that may -e su,,estive o. a psycho,enic nonepileptic seiBure include the
.ollowin,:
;ne..ectiveness o. multiple antiepileptic dru,s
;nduced -y stress or emotional upset
'ac* o. physical in0ury
'ac* o. headache or myal,ias .ollowin, convulsions
'ac* o. incontinence
2itin, the tip o. the ton,ue as opposed to the side or the lip
Fistory o. seAual or physical a-use
!5

7i,ns or symptoms su,,estive o. another conversion
?emory o. a ,eneraliBed ictal event
o ;ctal characteristics that su,,est nonepileptic seiBure include the .ollowin,:
!0

Gradual onset o. ictus
Prolon,ed duration "[4 min$
6typical or eAcessive motor activity such as thrashin,/ rollin, .rom one side to the
other/ pelvic thrustin,/ or arrhythmic "out%o.%phase$ 0er*in, such as alternatin, side
.leAion and eAtension o. the arms
(aAin, and wanin, amplitude
51
;ntelli,i-le speech
2ilateral motor activity with preserved consciousness
Clinical .eatures that chan,e .rom one spell to the neAt "ie/ nonstereotyped$
'ac* o. postictal con.usion
Postictal cryin, or cursin,
+irected violent acts
3yes closed durin, the ictus
25

Iesistance to eye openin,
Purpose.ul resistance to passive movements
Psycho,enic movement disorders
o Conversion disorder can imitate the entire spectrum o. movement disorders and include
tremor/ chorea/ myoclonus/ dystonia/ tics/ par*insonism/ *nee -uc*lin,/ and a host o. other
-iBarre ,ait distur-ances. 6 commonly used term .or a type o. this last phenomenon is an
astasia%a-asia ,ait pattern/ in which the patient ma*es wild movements o. the trun* and arms
durin, a ,ait evaluation -ut does not .all or err .rom a stressed ,ait such as a tandem or toe
,ait.
o @ariations o. astasia%a-asia have -een descri-ed. Psycho,enic camptocormia is a conversion
reaction mani.est -y patients am-ulatin, with a severe .orward .leAion posture at the
waist. <his was ori,inally descri-ed with military personnel durin, the early 20th century.
5
6
recum-ent%type ,ait has also -een reported in which a patient was .ound to wal* normally
with her eyes open however/ when her eyes were closed/ she would continue to wal*
while .allin, -ac*ward into the arms o. eAaminers. ;nterestin,ly/ the patient would continue
to eAhi-it a steppa,e ,ait as an attempt at wal*in,. (hen her eyes were opened/ she would
appear -ewildered to -e lyin, on the .loor.
4

o <he clenched .ist syndrome has -een descri-ed as a classic conversion reaction. <his is
mani.ested -y patients who eAhi-it a ti,htly closed .ist posture with resistance to all distal
hand movement due to severe pain. 6 .indin, to alert the clinician to this is paradoAical
sti..ness/ in which a chan,e in .in,er .leAion with motion o. the wrist does not occur. Clenched
.ist syndrome is seen a.ter minor trauma with associated pain and swellin,.
E

o Clinical symptoms or si,ns that may help distin,uish psycho,enic movements .rom or,anic
ones include the .ollowin,:
6-rupt onset o. symptoms
Character o. movements atypical o. reco,niBed patterns and have inconsistent
amplitude/ .re4uency/ and distri-ution
Characteristics o. movements chan,e over time
3ntrainment o. the tremor to the rate re4uested -y the eAaminer
7pontaneous remissions
?ovements disappear with distractions
?ovements increase with attention
Iesponse to place-o/ psychotherapy/ or su,,estion
ParoAysmal symptoms
Jono-0ective wea*ness or sensory chan,es also present
O-vious secondary ,ain "e,/ liti,ation/ health insurance claim/ military service$
3auses
Jeuroima,in, studies o. conversion disorders indicate hypo.unction o. the dominant hemisphere and a
conse4uent over activity in the non%dominant side. Other neuroanatomic .indin,s have -een seen with
52
conversion disorder. ?arshall et al reported chan,es in re,ional cere-ral -lood .low "rC25$ in a .emale
patient with a le.t le, paralysis and intact sensory modalities .or which no anatomic cause o. her
wea*ness could -e .ound. 6ttemptin, to move her paralyBed le, did not show activation o. contra
lateral motor corteA/ -ut rather contra lateral or-it%.rontal and anterior cin,ulated corteA were activated.
<his implied an anatomic inhi-ition o. primary motor corteA in one case o. hysterical paralysis.
2E

Others have shown via rC25 analysis that the le.t temporal re,ion has decreased rC25. rC25 studies
have also implicated the thalamus/ putamen/ and caudate on the side opposite the motor and sensory
conversion symptoms. Pu-lished reports show improved rC25 with resolution o. the conversion
symptoms.
8

5unctional ?I; studies have implicated the or-ito.rontal corteA and the anterior cin,ulate ,yrus as
active in mediatin, an inhi-itory e..ect on movement and sensation in patients with psycho,enic motor
and sensory complaints.
27

Jeuropsycholo,ical testin, shows evidence o. impaired attention and short%term memory.
Psychoanalytic theory postulates that conversion disorder is caused -y the repression o. unconscious
intrapsychic con.licts and conversion o. anAiety into physical symptoms.
'earnin, theorists -elieve that such symptoms develop .rom classical conditionin, that occurs durin,
childhood and that these learned -ehaviors arise a,ain as copin, mechanisms when the person is
su-0ected to overwhelmin, stress later in li.e.
7uch symptoms also can -e viewed as a .orm o. physical communication o. an emotionally char,ed
idea or .eelin, when one is una-le to ver-aliBe the con.lict -ecause o. personal or social ta-oos.
Differential Diagnoses
&t!er ,ro1lems to *e 3onsidered
<he di..erential dia,nosis o. conversion disorders is hi,hly dependent on the manner in which the patient
presents. Or,anic etiolo,ies must -e eAcluded. 7ome have su,,ested that conversion disorder not -e
considered a dia,nosis o. eAclusion/
!
althou,h a thorou,h medical and neurolo,ic clinical evaluation and
appropriate dia,nostic testin, is warranted prior to ma*in, the dia,nosis o. conversion. ;./ .or eAample/
a dia,nosis o. psycho,enic hemiparesis is considered/ or,anic etiolo,ies such as tumor/ stro*e/ multiple
sclerosis/ and others should -e ruled out. 6s in wor*in, up any disease/ the clinician must wei,h the ris*s and
-ene.its o. dia,nostic testin, to the patient8s overall condition.
Other pro-lems to -e considered include the .ollowin,:
3pileptic seiBures includin, .rontal lo-e epilepsy
7yncope % Cardio,enic/ hypovolemia/ orthostasis
7yncopal convulsion
?ovement disorders % <ics/ startle attac*s/ tremors/ myoclonus
7leep disorders % Jarcolepsy/ ni,ht terrors/ restless le,s syndrome/ rapid eye movement sleep
-ehavioral disorder
Other psychiatric disorders % +epressive disorders/ anAiety disorders/ panic disorder/ posttraumatic
stress disorder "P<7+$/ dissociative disorders/ psychotic disorders/ other somatic disorders/
intermittent eAplosive disorder
?alin,erin,
?edications % <oAicity "e,/ tremors .rom hi,h levels o. valproic acid$/ a*athisia ".rom neuroleptics and
possi-ly antidepressants$/ 3P7 .rom neuroleptics/ withdrawal .rom medications such
as -enBodiaBepines/ opiates/ and occasionally with antidepressants such as 77I;s or 7JI;s
53
3nvironmental eAposures to chemicals or heavy metals
+ru,s o. a-use "inhalants/ hallucino,ens$
5or+up
6a1orator" /tudies
Femiparesis
o ?I; o. -rain with di..usion%wei,hted ima,in,
o ?I; o. cervical re,ion
PseudoseiBure "PJ37$
o ?I; o. -rain
o 33G
o Prolon,ed video%33G monitorin,
o 3chocardio,ram
o Folter monitor
o <ilt%ta-le test
o Prolactin level #0 minutes a.ter the event: 6n elevation a-ove -aseline can occur with partial
seiBures/ ,eneraliBed seiBures/ or syncope/ -ut not with pseudoseiBures.
o Provocative 33G with place-o induction is no lon,er routinely per.ormed in many centers.
Psycho,enic movement disorders
o ?I; o. -rain
o <wenty%.our hour urine studies .or copper/ serum ceruloplasmin/ and slit lamp eAamination .or
evidence o. Mayser%5leisher rin,s to loo* .or evidence o. (ilson disease
o <hyroid%stimulatin, hormone/ thyroid peroAidase anti-odies/ thyro,lo-ulin anti-odies
o C2C count with smear .or acanthocytes
o 3rythrocyte sedimentation rate/ antinuclear anti-ody/ eAtracta-le nuclear anti-ody/
anticardiolipin anti-ody/ lupus anticoa,ulant
o F;@ anti-ody/ 'yme anti-ody/ anti%streptolysin O "67O$ anti-ody
o Fuman chorionic ,onadotropin
o Lrine and serum toAin screen .or stimulant or illicit dru, use
o +ru, levels "ie/ anticonvulsants/ di,oAin$
,rocedures
Fypnosis or 6mytal interview
<o ensure dia,nosis and to .acilitate disclosure o. underlyin, psychiatric issues durin,
psychiatric interview or therapy
8 m' intravenous sodium 6mytal 2.5C ,iven over 20 minutes has temporarily resolved cases
o. psycho,enic motor wea*ness and may have a lastin, e..ect in some cases.
28/ 2H
Other
protocols .or dosa,e are re.erenced.
#0

<his procedure carries si,ni.icant ris* and should -e carried out -y eAperienced
physicians. 7odium 6mytal is a -ar-iturate and carries ris* o. respiratory depression. ;t is
contraindicated in cases o. upper respiratory in.ection or airway edema/ hemodynamic
insta-ility/ si,ni.icant liver or *idney dys.unction/ and porphyria. 6 CPI cart with medications
and personnel trained in their use should -e availa-le in case o. emer,ency.
#0
<his is cited in
the literature as a techni4ue that may occasionally -e used to help .acilitate the ,atherin, o.
data -ut is not routinely per.ormed in many centers.
54
Fypnosis is used on occasion and may also .acilitate the data ,atherin, process. <his
techni4ue may also help alleviate the patient8s anAiety and aid in relaAation.
2rain P3< scan has demonstrated evidence o. le.t dorsolateral pre.rontal corteA hypo.unction.
7P3C< scan has shown decrease in re,ional -lood .low in the thalamus and -asal ,an,lia
contralateral to the de.icit.
6dvanced ima,in, is not dia,nostic o. conversion disorder/ and routine use .or this purpose is not
currently standard o. care.
7ee Causes .or rC25 studies.
8

Treatment
Medical 3are
Current understandin, o. the phenomenon o. conversion disorder implicates some role o. the unconscious in
the pathophysiolo,y o. this condition.
!0/ 28
;t is there.ore less li*ely to respond to treatment when the
mani.estations o. the conversion are con.ronted directly as a unitary method o. therapy. ?any patients who
eAperience a conversion disorder are una-le to understand this inner con.lict/ which is perhaps occurrin, on an
unconscious level. <hey may achieve resolution o. the con.lict/ as well as their physical symptoms/ once they
are ,ently made aware o. this connection. Once the patient is aware o. this/ the psycholo,ic currency o. the
symptom loses value/ and the symptom may -e allowed to improve.
Consider hospital admission: <he patient may not return .or .ollow%up a.ter -ein, ,iven a psychiatric
dia,nosis. 6 more rapid completion o. the dia,nostic wor*up is possi-le. ;n addition/ a parallel
investi,ation o. physical and psycholo,ic .actors can concomitantly -e pursued. One caveat to note is
that the clinical situation may -e worsened -y providin, the patient with the secondary ,ain he or she
is see*in,.
6void invasive dia,nostic and therapeutic interventions.
<act.ul presentation o. the dia,nosis to the patient includes the .ollowin,:
o 6void ,ivin, the patient the impression that you .eel there is nothin, wron, with them.
o +o not in.orm the patient o. the dia,nosis on the .irst encounter.
o Ieassure the patient that the symptoms are very real despite the lac* o. a de.initive or,anic
dia,nosis.
o Provide socially accepta-le eAamples o. diseases that o.ten are deemed stress%related "e,/
peptic ulcer disease/ hypertension$.
o Provide common eAamples o. emotions producin, symptoms "e,/ 4ueasy stomach when
tal*in, in .ront o. an audience/ heart racin, when as*in, someone .or a date$.
o Provide eAamples o. how the su-conscious in.luences -ehavior "e,/ nail -itin,/ pacin,/ .oot
tappin,$.
o Provide reassurance that no evidence o. an underlyin, neurolo,ical disorder is present -ased
on the tests that were per.ormed and that the pro,nosis .or recovery is very ,ood.
o Provide positive rein.orcement that the symptoms can improve spontaneously.
o ;n.orm patients that the symptoms are not volitional/ and no one -elieves that they are .a*in,.
o Provide a ,race.ul way .or the patient to improve .rom the symptoms. "6llow .or the symptom
to ,et -etter over time/ 0ust as an or,anic entity mi,ht improve.$ <his is perhaps the most
important point. 6 patient admitted to the neurolo,y ward with a psycho,enic ,ait disorder
should not -e dischar,ed suddenly once any mild improvement is seen. ;t may -e the -etter
part o. valor to hold a patient a day or so to ensure that the treatment is ta*in, hold.
55
Jo speci.ic pharmacolo,ic therapy is availa-le .or conversion disorder however/ medications .or
comor-id mood and anAiety disorders should -e considered. Care should -e ta*en to avoid
dependence%producin, psychotropic a,ents.
Physical therapy may -e warranted and is o.ten help.ul in providin, the patient an e,o%syntonic way
out as they are -ein, provided a -eni,n treatment to which they can respond and improve.
#!/ #2

;nstitute patient and .amily education sensitively.
Ie,ular short .ollow%up appointments with a neurolo,ist or a psychiatrist should -e provided to limit 3+
visits and unnecessary dia,nostic or invasive tests.
3onsultations
6 multidisciplinary approach to the treatment o. conversion disorder is -ene.icial.
28

Jeurolo,ist: <his is the primary evaluation where a conversion disorder is di..erentiated .rom
neurolo,ic diseases.
Cardiolo,ist: Consultation is warranted i. the patient has episodic alterations o. consciousness due to
concern over cardio,enic syncope.
Physical therapist: Consultation may -e warranted .or those with motor or ,ait symptoms.
#!

Psychiatrist: <his is ,enerally indicated when the symptoms persist. <his can aid in identi.ication o.
psycholo,ic stressors sym-olically lin*ed to the symptoms and other ris* .actors .or conversion
disorder. <he patient must -e in.ormed a-out the consultation -e.ore the psychiatrist does the
interview. Psychiatric treatments that have demonstrated e..ectiveness include the .ollowin,:
;nsi,ht Oriented 7upportive therapy: O..ers the client support and helps the patient to ,ain
insi,ht into their condition and possi-le tri,,ers.
2ehavioral therapy: 3Aamines the patient8s symptoms and teaches techni4ues to help them
-etter cope and alleviate the symptoms "e,/ -io.eed-ac* techni4ues$. <his is ideal .or those
lac*in, intelli,ence and insi,ht.
Psychodynamic therapy: <his may -e used .urther in the treatment process as a means to
help the patient ,ain insi,ht. Fowever/ patients with -orderline intelli,ence/ lac* o. motivation
or introspection capa-ilities/ important secondary ,ains/ or those with a tendency .or
-ehavioral actin, out are li*ely poor candidates.
Psycholo,ist: Psychosocial interventions that may -e help.ul include parado)ical intention therapy and
hypnosis.
!4

5amily therapy: ;nteractions and communication within the .amily are emphasiBed rather than
only .ocusin, on the individual patient.
!

(hatever the type o. therapy/ the most important element is a ,ood relationship with a con.ident/
supportive therapist.
Medication
7parse evidence eAists .or use o. medications .or the independent treatment o. conversion. ?edications that
have -een tried with success include tricyclic antidepressants/ haloperidol/ and also treatment with
electroconvulsive therapy "3C<$.
##/ #4
<reatment o. coeAistin, psycholo,ical or psychiatric disease is warranted.
Follo89up
,rognosis
7pontaneous resolution in most % 6pproAimately 75C
5!
Iecurrence o. same or di..erent conversion symptoms % 6pproAimately 25C in !5%year .ollow%up
studies
5alse%positive dia,nosis o. conversion disorder
o 6pproAimately 25C are dia,nosed with neurolo,ical disease in !0%year .ollow%up that could
account .or presentin, symptoms.
o ?ultiple sclerosis/ neurode,enerative diseases/ structural myelopathy/ peripheral neuropathy/
dystonia/ and myopathy accounted .or the .alse%positive dia,noses.
Good pro,nostic .actors % 6cute onset o. symptoms/ short duration o. symptoms/ healthy premor-id
.unctionin,/ hi,her intelli,ence/ a-sence o. coeAistin, psychopatholo,y/ presence o. an identi.ia-le
stressor/ male ,ender/ chan,e in marital status "marria,e or divorce$/ isolated sensory symptoms/ very
youn, a,e/ and ,ood premor-id medical health status.
!

Poor pro,nostic symptoms % PseudoseiBure "psycho,enic nonepileptic seiBure$/ psycho,enic tremor/
su-clinical "undia,nosed$ personality patholo,y/ concomitant medical illness/ the presence o. a stu..ed
animal -rou,ht to the hospital -y the patient/
#5
poor perception o. own well%-ein,/ motor symptoms/
and pendin, liti,ation.
!

Iecent retrospective study o. psycho,enic nonepileptic seiBure over a 5%year period showed 47C o.
patients were unemployed/ 2EC were not livin, independently/ and only !EC were seiBure .ree at 2!
months post dia,nosis o. psycho,enic nonepileptic seiBure.
#E

O. children with a dia,nosis o. conversion disorder/ 85C are symptom .ree at 5 years with a reported
improvement in status in another 5C.
#7

,atient 7ducation
7ensitively review the disorder with the patient and the .amily in such a way as to not place -lame.
+urin, such .ollow%up .or review o. completed ima,in, and other studies/ continue to emphasiBe the
importance o. pain or other symptoms that the patient may -e havin,.
Continue to reassure the patient that the ne,ative test results are ,ood news and -ode well .or their
eventual recovery.
5re4uent -rie. o..ice visits to ensure the eApected resolution o. their symptoms may -e help.ul.
(e- sites that may provide .urther in.ormation and support .or patient and .amily education include the
.ollowin,:
Rohns Fop*ins ?edicine/ Conversion +isorder
?ayoClinic.com/ Conversion disorder
?ental Fealth 5orum
Psych 5orums
Miscellaneous
Medicolegal ,itfalls
+elay in dia,nosin, or,anic disease due to lac* o. appropriate evaluation
Lnnecessary interventional or invasive dia,nostic tests resultin, in iatro,enic illness
Overly direct or con.rontational presentation o. the dia,nosis/ which may entrench the symptom and
lead to prolon,ed patient disa-ility
Multimedia
56
Media file 1= Frenc! neurologist Aean Martin 3!arcot s!o8s colleagues a female patient 8it!
!"steria at 6a /alpBtriCre( a ,aris !ospital.
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ournal of !eurology" !eurosurgery" # Psyc$iatry%&olume '()*+,ay -../p **'
6hat is wron! in conversion disorder?
&(DI"=RIA> $=%%(#"AR@+ $onversion disorder'
Ovsiew/ 5
+epartment o. Psychiatry ?C#077/ Lniversity o. Chica,o/ 584! 7. ?aryland 6venue/ Chica,o/ ;' E0E#7/ L76 .%
ovsiewOuchica,o.edu
01stract
6 disorder with many names
<he article -y 7tone et al "this issue/ p 5H!% 5HE$ ! addresses the natural history o. a disorder with many names/
none satis.actory. 5unctional/ hysterical/ psycho,enic/ medically uneAplained/ dissociative/ conversion%all the names
!2
.or this disorder have their .aults. Tet the disorder is common/ poses a mana,ement pro-lem .or doctors/ and carries
a poor pro,nosis. (hat is wron, with these patientsK
(hat is now clearly *nown not to -e wron, is the occult presence o. a neurolo,ical disorder. 7everal .ollow up
studies/ this one included/ show that the rate o. erroneous dia,nosis is low neurolo,ical disease is not -ein, missed
when conversion disorder is dia,nosed. <echni4ues o. neurolo,ical eAamination that allow reco,nition o. non%or,anic
mani.estations have -een descri-ed/ 2 althou,h patients with or,anic disease may%-ecause o. su,,esti-ility and the
demand characteristics o. the settin,/ ,enerate non%or,anic si,ns i. called on to do so -y inappropriate eAamination.
#
<he .ollow up studies also show that most patients with conversion disorder have persistin,/ or remittin, and
relapsin,/ somatic symptoms. ;n addition/ they have impairment o. psycholo,ical and social .unctionin, outside the
sphere o. medically uneAplained somatic symptoms. 5or eAample/ they o.ten have mood disorders/ sel.%in0urious
-ehaviour/ dissociative symptoms/ and interpersonal di..iculties.
(e have several clues a-out the .undamental nature o. the disorder. 5irstly/ many o. the patients have coeAistin,
or,anic -rain disease. 7econdly/ many have depressive disorders at the time o. presentation with medically
uneAplained somatic symptoms. <hese .acts point to the possi-ility o. disruption o. personality .unction -y -rain
disease or -y reversi-le a-normalities o. -rain state. <hirdly/ however/ many o. the patients eAperienced seAual or
physical a-use in childhood. <his in itsel./ and as a proAy .or widespread a-normality o. the childhood environment/
indicates that developmental .actors are commonly implicated in the personality distur-ance that ,ives rise "at times
only intermittently$ to conversion symptoms as well as "o.ten persistently$ to other .ailures o. psychosocial
.unctionin,. 4 6s is always the case with personality disorder/ herita-le temperamental .actors are li*ely to -e relevant
to vulnera-ility as well. 5 ;n addition/ patients o.ten adduce the presence o. contemporary stress in the ori,in o. the
symptoms. <he evaluator strains to discover the actual direction o. the causal arrow -etween personality dys.unction
and chaotic or stress.ul li.e events. ;n Clonin,er8s words/ the development o. a conversion or somatiBation disorder
occurs as part o. a compleA adaptive process involvin, non%linear interactions amon, multiple contri-utin, .actors. 5
;n summary/ conversion disorder appears to -e a disorder o. a..ect re,ulation and sym-olisation/ in which somatic
eAperiences and complaints serve to represent and convey emotional distress/ a purpose to which they are poorly
suited. ;deally/ the mana,ement o. these patients centres on the .ormation o. a treatment relationship not to catch the
patient out -ut to allow eAploration o. areas o. the patient8s li.e outside the presentin, symptoms and construction o. a
plan to reduce distress "includin, .ocused treatment o. commonly coeAistin, depressive disorder$/ and to develop
alternative ways o. see*in, attention and assistance .or distress.
Copyri,ht & 200# -y Rournal o. Jeurolo,y/ Jeurosur,ery ) Psychiatry. 6ll ri,hts reserved.
)nstitution= :omania=*MA9,D /ponsored N -i*n %n ,ia +sr 9a"LPass4#r'
/ Neurol Neurosurg %sychiatry !HH7A<+8#%88 " Ruly $
Clinical c$aracteristics of patients 2it$ motor disa1ility due to
conversion disorder% a prospective control group study
%ichael 8inBer,
a
Peter % Andersen,
a
*unnar Kull!ren
b

a
+epartment o. Jeurolo,y/ Lme\ Lniversity/ 7weden/
b
+epartment o. Psychiatry/ Lme\ Lniversity / 7weden
Correspondence to: +r ?ichael 2inBer/ +epartment o. Jeurolo,y/ 3s-0er, County Fospital/ ]ster,ade
80/ +M%E700 3s-0er,/ +enmar*.
Ieceived 22 Ruly !HHE and in revised .orm E 5e-ruary !HH7 6ccepted !0 5e-ruary !HH7
34/'1(-.'# Previous studies have su,,ested associations -etween conversion and many di..erent clinical
characteristics. <his study investi,ates

these .indin,s in a prospective desi,n includin, a control

,roup.
M'(H3"# <hirty consecutive patients with a recent onset o. motor disa-ility due to a conversion disorder were
compared with a control

,roup o. patients with correspondin, motor symptoms due to a de.inite

or,anic lesion. 2oth
,roups had a similar duration o. symptoms

and a compara-le a,e and seA pro.ile and were assessed on a
prospective

-asis. 2ac*,round in.ormation a-out previous somatic and psychiatric

disease was collected and all
!3
patients were assessed -y means

o. a structured clinical interview lin*ed to the dia,nostic system

+7? ;;;%I/ the
Familton ratin, depression scale/ and a special

li.e events

inventory.
*'#=<(# <he conversion ,roup had a hi,her de,ree o. psychopatholo,y with ##C o. the patients .ul.illin, the
criteria .or psychiatric

syndromes accordin, to +7?%;;;%I aAis ;/ whereas 50C had aAis

;; personality disorders
compared with !0C and !7C respectively

in the control ,roup. Conversion patients also had si,ni.icantly

hi,her
scores accordin, to the Familton ratin, depression scale.

6lthou,h patients with *nown neurolo,ical disease were
not included

in the conversion ,roup/ a concomitant somatic disorder was .ound

in ##C o. the patients and 50C
complained o. -eni,n pain. <he

educational -ac*,round in conversion patients was poor with only

!#C havin,
dropped out o. hi,h school compared with E7C in the

control ,roup. 7el. reported ,lo-al assessment o. .unctionin,

accordin, to the aAis @ on +7? ;@ was si,ni.icantly lower in conversion

patients/ who also re,istered si,ni.icantly
more ne,ative li.e

events -e.ore the onset o. symptoms than controls. 'o,istic re,ression

analysis showed that low
education/ presence o. a personality

disorder/ and hi,h Familton depression score were si,ni.icantly

associated with
conversion

disorder.
13N1<=#-3N <he importance o. several previously reported predisposin, and precipitatin, .actors in conversion
disorder is con.irmed.

<he results support the notion that conversion should -e treated

as a symptom rather than a
dia,nosis and that e..orts should -e

made in dia,nosin, and treatin, possi-le underlyin, somatic and

psychiatric

conditions.
Meywords: conversion disorder motor symptoms psycho,enic paralysis
C 0DD3 by 7ournal of #eurolo!y, #eurosur!ery, and Psychiatry
&m ( #sychiatry 1!37151'+1516, $eptember 2''!
doi7 1'116!9appia1p1!3:151'
W 2''! &merican #sychiatric &ssociation
$linical $ase $onference
Conversion Disorder
Cynthia '6 Stonnin3ton, '6D6, 7ohn 76 Barry, '6D6, and obert S6 /isher, '6D6, 2h6D6
Introduction
The diagnosis of psychogenic nonepileptic seizures has become

easier with the assimilation of studies on
the clinical categorization

of seizure+li2e events /10, video ??@ monitoring /20, measurement

of serum
prolactin /30, the selective use of neuropsychological

tests /40, and various other diagnostic methods
*uch less information

is available to the clinician on what to do next .ow should

the diagnosis best be
presentedK Ahat is optimal treatment,

and how best should it be individualizedK .ow well does treatment
wor2K Ae describe a patient with nonepileptic seizures and psychogenic

tremors as a starting point for a
discussion about how to proceed

after establishing a diagnosis of conversion disorder

Case 2resentation
E*s &,E a 53+year+old left+handed woman, was admitted to our epilepsy monitoring unit for evaluation
of a 4+month history of tremors, head bobbing, and episodic loss of awareness The onset of these
symptoms was 1 wee2 after she had visited an emergency department for a sudden+onset headache ,n
the emergency department, she developed transient numbness in her left face and arm and a left facial
droopF she also became increasingly distressed by the long delay in being attended to Bltimately, she
!4
left, Duite frustrated because a physician never examined her, although she had laboratory tests and
imaging studies *agnetic resonance imaging /*<,0 showed a right cerebellar lacunar infarct,
suggestive of a prior stro2e, but subseDuent imaging proved it to be artifactual
$ix days later, *s & started having events in which her speech became progressively more syllabic in
cadence .er arms, head, and then her body would sha2e for minutes without loss of consciousness
%orazepam provided transient relief
*s & later visited a naturopath, who began nec2 manipulations, which triggered new episodes /ie, she
uttered, E)ohooh,E while clapping both hands and feet, sometimes accompanied by visual changes,
tongue deviation, and unresponsiveness0 These episodes lasted up to 5 hours and occurred daily
&nxiety, music, and stress worsened her symptoms, whereas sleep improved them Cetween episodes,
she had a continuous head tremor
*s & was then admitted to an epilepsy monitoring unit for diagnosis with video ??@ recording &t
admission, she was ta2ing 4' mg9day of citalopram /later switched to escitalopram0, 3 mg9day of
lorazepam, 1 mg9day of benztropine, !'' mg9day of gabapentin, '1 mg9day of levothyroxine sodium, 65
mg9day of clopidogrel, 1 mg9day of clonazepam, 3' mg9day of nifedipine, and 15' mg9day of
fexofenadine ?xcept for levothyroxine sodium and fexofenadine, all medications had been prescribed
for neuropsychiatric symptoms
$everal typical episodes with sha2ing, tremor, and abnormal movements were recorded, with no
clinically significant accompanying ??@ changes &ll event types were captured during the patientIs
monitoring stay
,nitial evaluation by a psychologist uncovered a history of childhood and adolescent sexual abuse by *s
&Is father with a later discovery that he had also molested her sisters and daughters *s &Is symptoms
began around the seventh anniversary of her fatherIs death, after she discovered his abuse of her
daughters
.er verbal ,U was :4, her performance ,U was 1'5, and her full+scale ,U was :: .er verbal and visual
memory functions were intact )n the **#,+2 /50, *s & showed a classic Econversion - patternE7 on
scale 1 /hypochondriasis0 and scale 3 /hysteria0, her scores were elevated and considerably higher than
on scale 2 /depression0
3onversion disorder, the nonepileptic seizures subtype, was diagnosed on the basis of video ??@
recordings, history, and psychological testing The diagnosis was explained by a neuropsychologist and a
neurologist before *s &Is discharge from our video ??@ monitoring unit $he was initially s2eptical and
angry about this diagnosis but ultimately accepting $he was referred to a psychotherapist experienced in
wor2ing with patients with conversion disorder & movement disorder specialist diagnosed a psychogenic
tremor and voice disturbance The episodic sha2ing events largely remitted, but *s & continued to have
voice disturbances and head bobbing, which made her self+conscious, and she was no longer able to
wor2
Ahen she was first seen by one of us /3*$0, *s & reported that the depression caused by her loss of
!5
function had lasted more than a year but was improving .er psychotherapist was helping her identify
her normal emotions, express her feelings more directly, and ma2e choices that gave her a greater sense
of control The therapist also had pointed out the significance of the feelings that were elicited in the
emergency department &s a teenager, *s & had suicidal ideation triggered by an abortion that her father
reportedly performed &fterward, she visited an emergency department for persistent bleeding, where she
experienced terror, anger, and loss of control when left unattended for hours
Ae affirmed the diagnosis of conversion disorder, together with ma1or depression /recurrent in partial
remission0 and an anxiety disorder "espite some histrionic and dependent traits, *s & was not
considered to have a personality disorder $he was given a prescription for aripiprazole /5 mg bid0 for
residual depression, anxiety, and mood lability, in con1unction with discussion about its off+label use and
its potential to induce abnormal movements $he was encouraged to return for follow+up to learn self+
hypnosis to control the head tremor
)ne month later, *s & reported improved energy, focus, and concentration and said that she felt less
overwhelmed with everyday stress $he still had the head tremor and the effortful near+monosyllabic
speech ,n her second therapy session, she was found to be highly hypnotizable with the .ypnotic
,nduction #rofile /!0, scoring :5 on a 1'+point scale
*s & was then taught self+hypnosisF she focused on a visual image of herself floating on water with her
head stabilized in a floating ring $he successfully used this image to eliminate the head bobbing "uring
the therapy session, she practiced turning the bobbing on and off at will while in a trance+li2e state $he
was instructed to practice self+hypnosis 1' times a day *ore than a year later, she continued to use this
techniDue successfully .owever, the head bobbing recurred when she did not practice regular self+
hypnosis .er interpersonal psychotherapy visits decreased to monthly, her daily functioning improved,
and she had no recurrence of the seizure+li2e episodes $he stopped ta2ing lorazepam, clonazepam,
benztropine, and gabapentin but continued to ta2e escitalopram and aripiprazole $he has tried
discontinuing aripiprazole but felt anxious and functioned less well without it
Terminolo3y

E3onversion disorderE is the term used in the "$*+,- classification

system, originating from the
description by Creuer and 8reud

/60 of pseudoneurological symptoms resulting from conversion

of an
unconscious psychological conflict to somatic representation

)ther ad1ectives historically used to
describe the same phenomena

include EhystericalE and EpsychogenicE The seizure subtype

of conversion
disorder is often referred to as Epseudoseizures,E

but we chose to use the term Enonepileptic seizuresE
The term

EpseudoseizureE may incorrectly imply to the patient that the

symptom is not real E4onepileptic
seizuresE correctly describes

the symptoms without invo2ing a cause, and patients tend to

prefer this
term Ceginning treatment with a power struggle

over terminology wea2ens the doctor+patient
relationship, and

successful outcome often depends on good rapport

!!
2athophysiolo3y


&t present, treatment is not based on an understanding of the

underlying pathophysiology of conversion
disorder <ecent functional

neuroimaging studies point to a neurophysiological basis for

conversion,
albeit triggered by psychological processes 8unctional

imaging data suggest that neural circuits lin2ing
volition,

movement, and perception are disrupted in conversion disorder

/50, although conclusions have
been limited by the small number

of sub1ects, varying study designs, and heterogeneous populations

8rontal+subcortical circuits mediate many aspects of human behavior

/:0 The orbitofrontal cortex serves
as a control center, coordinating

various regions of the thalamus, amygdala, and cortex Coth

the
orbitofrontal cortex and the anterior cingulate cortex mediate

emotional and central executive functions
and are activated

when sub1ects suppress competing responses, suggesting an inhibitory

role /1'0 The
anterior cingulate cortex has been implicated

in the mediation of consciousness /110 Clood flow to the
anterior

cingulate cortex is positively correlated with emotional awareness

/120

#reliminary evidence suggests that during conversion reactions,

primary perception is intact, but
modulation of sensory and

motor planning is impaired by disruption of the anterior cingulate

cortex,
orbitofrontal cortex, and limbic brain regions /50

8urthermore, reduced activation of the frontal and
subcortical

areas involved in motor control is observed during conversion

paralysis /130, reduced
activation in somatosensory cortices

is seen during conversion anesthesia /140, and reduced activation

in
the visual cortex is noted during conversion blindness /150

*arshall and colleagues /1!0 measured regional cerebral blood

flow in a woman with left+side
conversion paralysis as she attempted

to move her paralyzed leg and also as she moved her nonparalyzed

right leg .er attempt to move the paralyzed leg failed to activate

the right primary motor cortex, and
there were significant activationsRnot

observed under other conditionsRof the right anterior

cingulate
cortex and the right orbitofrontal cortex /1!0 Aith

the same experimental design, .alligan and
colleagues /160 measured

brain activity in a man with hypnotically induced paralysis

of the left leg They
found similar activations of the right

anterior cingulate cortex and the orbitofrontal cortex and no

activation of the motor and premotor cortex The activations

of the anterior cingulate cortex and the
orbitofrontal cortex

apparently represented inhibition of the sub1ectIs voluntary

attempt to move his left
leg )ther functional imaging studies

of patients with acute conversion paralysis /15, 1:0 and astasia+
abasia

/2'0 also implicated disruption of striatothalamocortical premotor

pathways, with possible
pathological inhibition from activation

of the anterior cingulate cortex and the orbitofrontal cortex

Comorbid Conditions


!6
Therapy for nonepileptic seizures must ta2e into account the

li2elihood that a patient with conversion
disorder will also

meet criteria for another axis , disorder Typical comorbid

diagnoses include mood
disorders, panic disorder, generalized

anxiety disorder, posttraumatic stress disorder, dissociative

disorders, social or specific phobias, and obsessive+compulsive

disorders /21X230 &xis ,, pathology and
having close

relatives with psychiatric illness or severe somatic disease

are also common /210 Treatment
of the associated psychiatric

conditions will benefit overall functioning and recovery )ur

patient profited
from treatment of comorbid depression, which

improved her overall functioning and responsiveness to
psychotherapeutic

interventions

#atients with conversion symptoms commonly report a history

of physical or sexual abuse & study
comparing 54 patients who

had conversion disorder with 5' matched patients who had an

affective
disorder /240 found a higher incidence and longer

duration of physical or sexual abuse and more
incestuous experiences

in patients with conversion disorder

Ahether some of our patientIs memories were false is un2nown

.aving false memories may be a form
of conversion, with pathophysiological

mechanisms similar to those of motor conversion /250 &lthough

specific details of any abuse may be Duestionable, many patients

undoubtedly experienced substantial
family dysfunction, attachment

disorders, or impaired ob1ect relations ,n contrast to patients

with motor
conversion symptoms, patients with nonepileptic seizures

are more li2ely to have experienced childhood
abuse /2!0

,n patients with nonepileptic seizures, depression is the most

common comorbid diagnosis, occurring in
12GX1''G &lso

common are anxiety disorders /11GX5'G0, dissociative disorders

/:'G0, other
somatoform disorders /42GX:3G0, and personality

disorders /33GX!!G0 /260 The strong overlap of
nonepileptic

seizures with dissociative disorders has prompted some authors

to propose reclassifying
conversion disorders within the dissociative

disorders spectrum /250

#atients with nonepileptic seizures appear to have greater psychopathology

and somatization, as
measured by personality tests, than healthy

comparison sub1ects or patients with epilepsy )wczare2 /2:0

found that such patients scored significantly higher on four

of five **#, somatization parameters than
patients with mixed

epilepsy and nonepileptic seizures or epilepsy alone & tendency

to discount the
importance of psychological factors contributing

to illness, denial of external stressors, and an external
locus

of control are additional cognitive factors shown to be more

prevalent in patients with nonepileptic
seizures than in patients

with epilepsy /3'0 Ahen <euber and colleagues /310 compared

55 patients with
nonepileptic seizures with !3 with epilepsy

and 1'' healthy volunteers, they found that the patients with

nonepileptic seizures had more personality abnormalities and

that outcomes varied by personality profile
3ragar and colleagues

/320 further defined three clusters of personality subtypes

among patients with
nonepileptic seizures and 6: epilepsy patients

prospectively evaluated in an epilepsy monitoring unit and
noted

significant differences between the two groups )ur patientIs

relative lac2 of severe axis ,,
pathology may have contributed

to her ability to benefit from treatment

!5
Treatment
Treatment begins with presentation of the diagnosis ?ven before

a formal discussion of treatment
options, the diagnostic wor2up

and the presentation of the diagnosis offer opportunities to

improve the
patientIs outcome 3onversely, the use of

intravenous saline or placebo patches to induce nonepileptic

seizures for diagnostic purposes may be perceived by the patient

as dishonest, and therefore, it may ris2
serious damage to the

doctor+patient relationship /33, 340 ,t may even induce unrepresentative

nonepileptic seizures in patients with epilepsy .ypnosis can

avoid the pitfall of deception, if its purpose
and aims are

fully explained in advance )nce in a trance+li2e state, patients

are directed to turn the
seizure+li2e event EonE and EoffE /350,

a techniDue that can be used again for treatment purposes

*any physicians are uncomfortable presenting a diagnosis of

conversion disorder to a patient &ngry
reactions from patients

may derive from a perceived sense /sometimes based on reality0

of abandonment
by a physician & prior experience of abandonment

or abuse by authority figures compounds these
reactions /3!0

Therefore, careful attention to how the diagnosis is presented

can often help maintain an
ongoing therapeutic relationship

Ley points are listed in &ppendix 1

& discussion of the diagnosis must be timed sensitively to occur

after confirmation of the diagnosis but
before the patient has

been upset by indirect and fragmentary discussions /360 "iscussion

ideally should
ta2e place after the patient and family have

agreed that representative events have been captured by video
??@ monitoring ,f not all types of events have been characterized,

as is often the case, then the clinician
should openly admit

that other types of episodes may be extant & standard protocol

for presenting the
diagnosis /350 can be individualized and

updated to conform to the current base of evidence and
experience

Ae also find it useful to give printed educational materials

on conversion disorder to patients
and their families Cecause

patients with conversion disorder may be less open to psychological

explanations than are patients with defined neurological illness

/3'0, the groundwor2 for a discussion of
psychological and stress+related

factors must be laid carefully

Ae start with a recapitulation of the results of the tests,

central to which is the observation that brain
waves were unremar2able

during the episode &lthough some brief, focal, and deeply situated

seizures
show no scalp+recorded ??@ changes /3:0 and may be

associated with histrionic behaviors /4'0, epilepsy
episodes

severe enough to alter consciousness, memory, responsiveness,

and generalized motor activity
should show ??@ correlates Ae

avoid mentioning ErealE or EunrealE seizures because patients

should
2now that the medical care team believes that the symptoms

are ErealE even if the patients are not
epileptic and that they

have a negative impact on the patientIs functioning and

Duality of life Ae reassure
such patients that we 2now they

are not intentionally producing their episodes and that the

episodes do
not mean that they either are fa2ing it or are EcrazyE

The absence of epilepsy is presented as good news
Ae admit

that we do not 2now what causes nonepileptic seizures, but they

result in general from
interactions between the subconscious

mind and the body

&t this point, we explain that many patients with conversion

disorder have a past history of trauma or
stress during the

critical developmental years and tend to be persons who value

being emotionally
Estrong,E which causes them to discount emotional

reactions when coping with difficult situations ?ven
though

the traumatic events may have occurred years ago, the physical

symptoms usually begin later in
!:
response to newRand often

not immediately apparentRtriggering events The physician

may also add
that prior to their disabling symptoms, patients

with conversion disorder are typically highly competent,
caring

individuals who prefer to focus on others rather than themselves

#atients who relate to these
generalizations will find it easier

to begin to accept the diagnosis of conversion disorder and

understand
the need for psychological interventions

The neurologist may express the view that conversion disorder

can coexist with neurological illness /ie,
epilepsy0, even

when the neurological illness is not detected $ome patients

with partial seizures elaborate
their symptoms under observation

/410 but do have epilepsy The possibility of a mixed epileptic

and
nonepileptic pathogenesis should be used as mutual motivation

for ongoing vigilance )ffers to continue
to follow the patient

as long as symptoms persist are usually welcomed, although such

visits can span a
relatively long interval because the goals

of the visits are surveillance and avoidance of abandonment

rather than medical therapy ,nstead of the automatic and usually

futile addition of more medication, the
neurologist should wor2

collaboratively with mental health providers &ll too often,

neurologists and
psychiatrists convey differing views on the

cause of symptoms and the ways to control them /420
Therefore,

communication between the neurologist and psychiatrist will

decrease these mixed messages
and set the stage for more successful

treatment

Treatment 8ptions
&n overview of the existing medical literature on the treatment

of nonepileptic seizures has been
presented elsewhere /430

&lthough most reports of treatment are anecdotal, there are

a growing number
of prospective trials

&s a practical matter, we suggest a treatment paradigm for patients

with conversion disorder that ta2es
into account the ris2 factors,

perpetuating factors, and triggering events 8igure 1 8irst,

the treatment team
should consider the relevant ris2 factors

for any given patient

6'
1iew lar3er version /!4L07
=in this window>
=in a new window>

8igure 1 Ciopsychosocial
3onceptualization of
3onversion "isorder
a

a
&fter a diagnosis is
presented, treatment
begins by directly
addressing relevant ris2
factors /eg, psychiatric
comorbid conditions and
communication
difficulties0 4ext,
psychological
interventions should
focus on minimizing the
perpetuating factors and
recognizing triggering
events These data are
from references 3', 43,
45, and 5'
,f the patient has substantial cognitive impairment or communication

difficulties, treatment is best
focused on simple behavioral

interventions, physical therapy /44X460, reassurance,

and helping the
patient verbalize distress

Aor2ing with the family unit may be necessary when family and

sociocultural factors predominate,
particularly in children

and adolescents 8amily therapy interventions help the patient

and family
recognize and address 2ey issues that may be fueling

the symptoms 8or example, in an analysis of
videotaped family

interviews of adolescent patients, an unspea2able dilemma was

imposed by family or
social circumstances in 13 of 14 cases,

leading patients with nonepileptic seizures to suppress emotional

distress /450 &n open+label trial of family therapy with a

problem+centered systems approach /4:0 for
61
patients with nonepileptic

seizures is in process

<ecognition and treatment of comorbid psychiatric conditions

are almost always necessary for symptom
resolution ,ndeed,

it may be sufficient to treat the comorbid condition in con1unction

with proper
presentation of the conversion disorder diagnosis

.owever, if patients continue to be symptomatic after these

ris2 factors have been addressed, then
psychological treatments

that focus more directly on Eperpetuating factorsE will be necessary

#atientsI
/and physiciansI0 reactions to their conversion

symptoms can serve to unwittingly perpetuate them
&voidant

behaviors, minimization of psychological factors, and suppression

of expression of distress
reinforce an external locus of control

,t is easy to see why cognitive behavior therapy would lend

itself
well to addressing these issues ,t is specifically helpful

in addressing illness beliefs and denial of stress
and in modifying

the locus of control /5'0 #sychodynamic psychotherapy can also

serve to help patients
reframe their world view through empathic

interpretations and the development of insight, enabling the

process of wor2ing through past trauma rather than relying on

dissociation as a defense /510 Coth
approaches will increase

awareness of Etriggering events,E ultimately leading to greater

sense of control
of symptoms

2sychotherapy
3ognitive behavior therapy for nonepileptic seizures is based

on the concept that symptoms occur when a
patient is confronted

with Eintolerable or fearful circumstancesE and that such symptoms

are maintained
by a Evicious circle of behavioral, cognitive,

affective, physiological, and social factorsE /5'0 $pecific

techniDues include graded exposure to feared or avoided situations,

use of problem+solving techniDues,
and the reframing of distorted

cognitive beliefs about their illness and powerlessness &n

open trial of
cognitive behavior therapy decreased the freDuency

of nonepileptic seizures and improved psychosocial
functioning

/5'0 )ne ongoing controlled study is evaluating the effectiveness

of cognitive behavior
therapy for patients with nonepileptic

seizures /430, but more well+controlled clinical trial data

are
needed

&t least five sessions of EcounselingE by a therapist affiliated

with a comprehensive epilepsy center
proved to be more effective

in reducing nonepileptic seizures than therapy administered

by a nonaffiliated
therapist, as measured by a retrospective

telephone follow+up survey /520 <eferral to a therapist
2nowledgeable

about nonepileptic seizures or conversion disorder, as was the

case for our patient, may
also increase the li2elihood of a

better outcome

To our 2nowledge, there are no prospective controlled trials

of psychodynamic psychotherapy for
nonepileptic seizures /430,

but Lalog1era+$ac2ellaresIs /510 extensive review of 15

years of
psychodynamic psychotherapy experience with patients

with nonepileptic seizures provides a good
overview of that

approach The primary focus of this therapy is on the role of

trauma and dissociation
/510, inadeDuate attachment, and the

patientIs difficulty in coping with intrapsychic conflict

and anxiety
/530

@roup therapy, preferably in con1unction with concurrent individual

therapy, offers advantages of
reinforcing psychoeducational

concepts, while providing the opportunity for patients to learn

from and
help each other Three noncontrolled studies have reported

its benefit for patients with nonepileptic
62
seizures /3!, 54,

550 *ultidisciplinary inpatient treatment may be preferred

for patients with severe and
prolonged symptoms /5!X550,

but such resources are not available for many patients

(ypnosis
.ypnosis has been advocated for the treatment of conversion

symptoms since the time of 3harcot, (anet,
and 8reud 4euroimaging

data reinforce the idea that conversion symptoms and hypnosis

involve
common neurological pathways, and the high hypnotizability

of these patients invites the use of hypnosis
in their treatment

& study of 44 outpatients with conversion disorder /5:0 randomly

assigned to hypnosis
or a waiting list found greater improvement

at 3 months with hypnosis &nother study comparing a
comprehensive

treatment program comprising intensive group therapy, social

s2ills training, creative
therapy, sports therapy, and physical

therapy with or without hypnosis /550 showed no added benefit

from
hypnosis for resolving conversion symptoms and no predictive

value of hypnotizability for treatment
outcome .ypnosis can

be a useful ad1unctive treatment, but it is not essential for

improvement &
comprehensive approach is li2ely to be the most

effective .ypnosis without other forms of psychiatric
treatment

may decrease conversion symptoms but have less impact on overall

psychopathology

)ur patient used hypnosis to reduce head tremor, but she also

benefited from individual therapy using
insight+oriented and

cognitive behavior approaches and from medication treatment

for overall
improvement in functioning, Duality of life, and

self+esteem

2harmacotherapy
@iven the lac2 of data for controlled trials on the pharmacological

treatment of conversion disorder, the
current practice is to

use medications appropriate for the comorbid psychiatric and

somatic symptoms and
to withdraw antiepileptic drugs unless

they are benefiting the comorbid conditions &necdotal studies

report improvement with selective serotonin reupta2e inhibitors

/$$<,s0, beta+bloc2ers, analgesics, and
benzodiazepines /!'0

&n open trial of antidepressants in patients with psychogenic

movement disorder
and recent or current depression also showed

that class of medications to be effective in reducing
conversion

symptoms /!10 &n ongoing randomized controlled study is evaluating

the effectiveness of
sertraline for patients with nonepileptic

seizures and comorbid depression and anxiety /430

)ur patientIs condition improved with an $$<,, but her

conversion symptoms fully resolved only after
she started ta2ing

a low+dose atypical antipsychotic medication 4o controlled

studies have evaluated
atypical antipsychotics for the treatment

of conversion reactions, particularly in the absence of fran2

paranoia or psychosis <eports of the benefits of antipsychotic

medications in conversion reactions /3!,
!2X!40 are anecdotal

4o general rule exists about whether to continue ta2ing antiepileptic

drugs after establishing a diagnosis
of nonepileptic seizures

,f nonepileptic seizures seem to be the exclusive diagnosis,

and the patient
willingly enters into treatment, then antiepileptic

drugs usually can be tapered ?ven in this setting, it is
prudent

to discontinue one medication at a time, each over a span of

a few wee2s or months Carbiturates
and benzodiazepines are

habit forming and should be tapered gradually Ahere nonepileptic

seizures and
epilepsy are believed to coexist, at least one

antiepileptic drug should be maintained *any antiepileptic

drugs provide concomitant mood+stabilizing actions and are sometimes

continued for this reason

Transcranial 'a3netic Stimulation
63
*ore recent anecdotal reports about the benefit of transcranial

magnetic stimulation in refractory
conversion paralysis /!50

and somatization associated with posttraumatic stress disorder

/!!0 are of
particular interest given the functional imaging

data that infer disruption of the frontal+subcortical
circuits

,f transcranial magnetic stimulation can target the specific

frontal+subcortical circuit thought to
be involved in the development

of conversion symptoms, then perhaps such future procedures

will
ultimately benefit patients with conversion reactions

Course and 2ro3nosis

Cetween 5'G and :'G of the patients with conversion disorder

exhibit short+term resolution of
symptoms after reassurance,

but as many as 25G of these responders relapse or develop new

conversion
symptoms over time /!6, !50 & longer duration of

symptoms, psychiatric comorbidity, subacute
presentation, and

tremor or nonepileptic seizure subtypes are associated with

a worse prognosis

&mong patients with nonepileptic seizures, even those with symptomatic

improvement may remain
disabled /!:0 ,n one outcome study of

5! such patients, only half of the patients had a resolution

of
nonepileptic seizures a mean of 15 years after diagnosis,

and many still exhibited depressive symptoms,
suicidal ideation,

and suicide attempts & patientIs perception of good health

and occupational functioning
is correlated with resolution,

which suggests that interventions that focus on improving functioning

and
self+esteem could aid treatment /6'0

Conclusions

?arly recognition of a conversion disorder will limit unnecessary

tests and medications %ong+term
benefit li2ely reDuires a comprehensive

treatment approach, recognition of ris2 factors, and treatment

of
comorbid conditions, with a focus on cognitive styles that

perpetuate symptoms The Duality of the
doctor+patient relationship

can influence outcome .ard+to+treat patients may engender feelings

of
powerlessness, frustration, and mistrust in their treaters,

which, if unprocessed, may lead to a poor
relationship and excessive

use of medications, tests, and procedures

There are few published reports on prospective studies or controlled

trials of treatment for patients with
nonepileptic seizures

The existing medical literature supports a multidisciplinary

treatment approach,
with specific interventions, such as cognitive

behavior therapy for cognitive restructuring and
psychodynamic

therapy for addressing symptom connections to trauma and dissociation

&d1unctive
64
group therapy or family therapy wor2s well for certain

patients .ypnosis can be beneficial, although it is
not essential

for a good outcome (udicious medication treatment for comorbid

disorders, alone or in
combination with psychotherapy, is often

needed for sustained recovery

/ootnotes
<eceived "ec 23, 2''5F revised *ay 5, 2''!F accepted *ay 16,

2''! 8rom the "ivision of &dult
#sychiatry, *ayo 3linicF and

the "epartment of #sychiatry and Cehavioral $ciences and the

"epartment
of 4eurology, $tanford Bniversity *edical 3enter,

$tanford, 3alif &ddress correspondence and reprint
reDuests

to "r $tonnington, "ivision of &dult #sychiatry, *ayo 3linic,

134'' ?ast $hea Clvd,
$cottsdale, &Y 5525:The authors than2

%ois Lrahn, *", for her help

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4M/ 2000#20:!488%!48H " # Rune $
(ditorials
#ew approaches to conversion hysteria
&unctional imaging may improve understanding and reduce mor0idity
Patients with hysterical conversion/ now called conversion disorder -y the main L7 psychiatric ,lossary/
!
o.ten
present

with stri*in, neurolo,ical symptoms such as wea*ness/ paralysis/

sensory disorders/ or memory loss/ in the
a-sence o. any patholo,y

that could -e responsi-le. ?ost patients will -e re.erred to a

neurolo,ist or psychiatrist a.ter
consultin, their .amily

doctor.
6:
6s many as 4C o. those attendin, neurolo,y outpatient clinics in the Lnited Min,dom have -een estimated to have
conversion

disorders.
2
7imilar rates have -een reported .or -oth in and

outpatient clinics in other 3uropean

countries.
3mpirical research on hysterical conversion has la,,ed -ehind theoretical speculation. Iecent advances in .unctional
ima,in,

"positron emission tomo,raphy scannin,$ and co,nitive neuropsycholo,y

have/ however/ made the .ield more
amena-le to investi,ation.
#
Mey clinical and theoretical pro-lems remain over case de.inition

and di..erential
dia,nosis/ the psycholo,ical mechanisms underlyin,

conversion hysteria/ and how patients are -est

mana,ed.
+espite attempts over the past century to a-olish and reinstate the condition -y usin, di..erent la-els/ conversion
hysteria

continues to attract controversy.
4

5
<he dia,nosis is considered

pe0orative/ and its place within psychiatric
classi.ication remains

uncertain. <here is no ,enerally accepted eAplanation .or how

a psycholo,ical stress can
convert into "o.ten hi,hly selective$

symptoms. ;n this respect/ conversion hysteria retains Sthe dou-t.ul

distinction
amon, psychiatric dia,noses o. still invo*in, 5reudian

mechanisms as an eAplanation.S
E

<he dia,nosis o. conversion hysteria is typically made a.ter eAcludin, or,anic patholo,y and identi.yin, a relevant
psycholo,ical

stressor. Pro-lems with dia,nosis include the eAtent to which

or,anic disorders can and should -e
eAcluded a,reement on what

constitutes relevant psycholo,ical con.lict and the criteria

used to eAclude

malin,erin,.
"echnolo!y reduces the risk of missin! or!anic disease
<here are .ew/ i. any/ empirical data to support

the dia,nostic criteria ,iven in psychiatric ,lossaries/ and in

clinical
practice intuition and eAperience play a lar,e part in

the dia,nosis. <here is little evidence to determine what
constitutes

a relevant psycholo,ical stressor. 6 recent study/ however/ showed

that the use o. modern technolo,y
minimised the li*elihood o.

missin, or,anic disease.
7
;t is li*ely that particular people

may -e at ris* -ecause o. some
underlyin, vulnera-ility. 3vidence

.or this may prove di..icult to .ind/ and it remains impossi-le

to eAclude malin,erin,
as a potential

cause.
5or much o. this century the search .or the neurolo,ical systems responsi-le .or conversion hysteria was lar,ely
i,nored.

<he cruA o. the pro-lem is to eAplain how a-normal psycholo,ical

states can produce speci.ic/ lon, term
neurolo,ical symptoms and

disa-ility in patients "who claim not to -e consciously responsi-le$

in the a-sence o.
detecta-le patholo,y.
4

Iecent evidence .rom .unctional ima,in, provides some indication o. the possi-le -rain areas involved. <he
.unctional ima,in,

study -y ?arshall et al o. a patient with le.t sided paralysis

"-ut with no detecta-le lesion$ .ound
that when the patient tried

to move her a..ected lim-/ considera-le activity was seen in the

ri,ht anterior cin,ulate and
or-ito.rontal corteA.
8
<hese activations

were identi.ied as the pre.rontal structures responsi-le .or inhi-itin,

the
patient8s volitional

movements.
<o -rid,e the ,ap le.t -y the traditional overreliance on psychodynamic theory/ several neuropsycholo,ical accounts
have emer,ed.
#
;nstead o. tryin, to eAplain conversion hysteria/ these are more

concerned with wor*in, out how
impairments to normal co,nitive

processes such as volition/ memory/ and motor and sensory control

may cause
clinical symptoms.
H

5'
<he conceptual lin* -etween hypnosis and hysteria has also -een hi,hli,hted. Particularly in the acute sta,e/
conversion symptoms

and hypnotic phenomena share many .eatures/ to the eAtent that

eAperiments on hypnosis
"considered a *ind o. controlled hysteria$

have lon, served as eAperimental analo,ues .or the study o. hysterical

symptoms. <he view that conversion symptoms can -e use.ully thou,ht

o. as an autosu,,estive disorder ,ains some
support .rom a recent

.unctional ima,in, study -y Falli,an et al/ which showed that

the areas o. the -rain activated -y
paralysis induced -y hypnosis

are similar to those activated in hysterical paralysis.
8

!0

!!

<here have -een no controlled studies o. treatment o. patients with conversion hysteria. <he uncontrolled case
reports and

series that eAist are di..icult to evaluate/ as some patients

improve spontaneously and the psycholo,ical
-ene.its o. any intervention

may -e more important that the speci.ic

intervention.
<he lessons learnt in the treatment o. chronic .ati,ue syndrome and other somato.orm disorders may -e applica-le.
!2

<here

is potential in usin, a co,nitive -ehavioural approach/ avoidin,

rein.orcement o. the a-normal illness -ehaviour/
and .acilitatin,

more appropriate lin*s -etween li.e situations and physical symptoms.

'i.e events and social
circumstances can dramatically chan,e a

person8s pro,nosis/ and there is emer,in, evidence that patients

who
eAperience a chan,e in circumstances and li.e events a.ter

the onset o. their symptoms have improved outcomes.
!#

3vidence is -uildin, that althou,h conversion hysteria causes ma0or disa-ility/ it is almost certainly not a disease with

a speci.ic patholo,y. 6lthou,h the dia,nosis carries a ne,ative

connotation .or patient and doctor/ its aetiolo,y and
mana,ement

deserve .urther

study.
(hether new developments in .unctional ima,in, and co,nitive neuroscience can move the de-ate -eyond disputes
a-out how the

disorder should -e classi.ied to testa-le hypotheses a-out the

neuropsycholo,ical and social
mechanisms involved in the disorder

remains to -e

seen.
Peter 6 9alli!an/ M*1 senior research fellow.
7chool o. Psycholo,y/ Lniversity o. Cardi../ PO 2oA H0!/ Cardi.. C5! #TG
$hristopher 8ass/ consultant in liaison psychiatry.
+epartment o. Psycholo,ical ?edicine/ Rohn Iadcli..e Fospital/ OA.ord OP# H+L
Derick " 6ade/ consultant in neurological disa0ility.
Iivermead Ieha-ilitation Centre/ 6-in,don Ioad/ OA.ord OP! 4P+
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CiteL'i*e Complore Connotea +el.icio.us +i,, Ieddit <echnorati (hat8s thisK
Rapid Responses+
Iead all Iapid Iesponses
$onversion 9ysteria and 9ypnotic Paralysis+ "he #ature of their #europhysiolo!ical Simlarity
7alvador @ale
-m0.com/ E Run 2000 95ull teAt:
Re+ $onversion 9ysteria and 9ypnotic Paralysis+ "he #ature of their #europhysiolo!ical Simlarity
;an Pennell
-m0.com/ E Run 2000 95ull teAt:
"he neurolo!y of hysteric conversion
6 Chaudhuri
-m0.com/ 8 Run 2000 95ull teAt:
Rapid Responses to+
3+;<OI;6'7:
Peter ( Falli,an/ Christopher 2ass/ and +eric* <
(ade
#ew approaches to conversion hysteria
2?R 2000 #20: !488%!48H 95ull teAt:
:apid :esponses= /u1mit a response to t!is
article
Rapid Responses published+
3onversion 4"steria and 4"pnotic ,aral"sis= T!e Eature of t!eir
Eeurop!"siological /imlarit"
-al,a'#r Oal (6 Jun 2000)
:e= 3onversion 4"steria and 4"pnotic ,aral"sis= T!e Eature of t!eir
Eeurop!"siological /imlarit"
%an Pnnll (6 Jun 2000)
T!e neurolog" of !"steric conversion
1 Chau'huri (8 Jun 2000)
52
$onversion 9ysteria and 9ypnotic Paralysis+ "he #ature of their
#europhysiolo!ical Simlarity
E Rune 2000
7alvador @ale/
Psychiatrist
$ntiguo Hospital
1oncepcion 4eistegui,
*egina 7, 1% 0?0@0, Me)ico
":&:
7end response to
0ournal:
Ie: Conversion
Fysteria and Fypnotic
Paralysis: <he Jature
o. their
Jeurophysiolo,ical
7imlarity
Falli,an and others "!/ 2$ descri-ed in !HH7 a .emale patient
with a le.t%sided hysterical paralysis. <hey su,,ested that -oth
ri,ht or-ito% .rontal and ri,ht anterior cin,ulate corteA inhi-ited
the pre.rontal "willed$ activity on her ri,ht primary motor corteA.
7ince the activated -rain areas durin, paralysis induced -y
hypnosis are similar to those activated in hysterical paralysis/
Falli,an has proposed that conversion symptoms can -e
use.ully thou,ht o. as an auto%su,,estive disorder "2$. ; -elieve
that an alternative interpretation a-out these data is pertinent.
<he anterior cin,ulate corteA "a part o. the -rain>s lim-ic
system$ has -een shown to -e activated durin, hypnosis
without and with di..erent *ind o. su,,estions "#$. 6lthou,h the
nature o. the .unctional role o. the anterior cin,ulate corteA in
hypnosis remains to -e elucidated/ it can -e considered that
this corteA as a whole/ inte,rate input .rom various sources
includin, motivation/ evaluation o. error/ and representations
.rom co,nitive and emotional networ*s "4$. <he role o. the
anterior cin,ulate corteA as an error detection and correction
su-system o. the -rain su,,ests that its activation may -e
secondary to opposite actions within the co,nitive domain/ i.e./
the willed action and the con.lictive "pro-a-ly superimposed$
suppressive order "hypnotic or hysterical$. Lnder this
interpretation/ the reported similarities -etween these two
conditions do not represent a primary neurophysiolo,ical
mechanism that can ,ive us some insi,ht a-out the conversion
hysteria pathophysiolo,y.
?oreover/ the ri,ht anterior cin,ulate corteA is also activated
durin, auditory hallucinations induced -y hypnosis "5$/ -ut we
do not consider the hallucinatory eAperience as an auto%
su,,estive disorder. Fence/ with the *nown data .rom -rain
ima,in, we cannot accept the view si,nalled -y ?arshall/
Falli,an "!/ 2$ and others considerin, that Santerior cin,ulate
provides a meetin, place .or interactions -etween co,nitive
and motivational processes/ particularly in relation to the
53
,eneration o. motor outputS.
!.% ?arshall RC/ Falli,an P(/ 5in* GI et al. <he .unctional
anatomy o. a hysterical paralysis. Co,nition !HH7 E4 : 2! % 28
2.% Falli,an P(/ 6thwal 27/ Oa*ley +6 et al. ;ma,in, hypnotic
paralysis : implications .or conversion hysteria. 'ancet 2000
#55 : H8E % H87
#.% Iainville P/ Fo.-auer IM/ Paus < et al. Cere-ral
?echanisms o. Fypnotic ;nduction and 7u,,estion. Rournal o.
Co,nitive Jeuroscience !HHH !! : !!0 % !25
4.% 2ush G/ Posner ?;. Co,nitive and 3motional ;n.luences in
6nterior Cin,ulate CorteA. <rends in Co,nitive 7ciences 2000
4 : 2!5 % 222
5.% 7Bechtman F/ (oody 3/ 2owers M7 et al. (here the
ima,inal appears real : 6 positron emission tomo,raphy study
o. auditory hallucinations. Proc Jatl 6cad 7ci L76 !HH8 H5 :
!H5E % !HE0
Re+ $onversion 9ysteria and 9ypnotic Paralysis+ "he
#ature of their #europhysiolo!ical Simlarity
E Rune
2000
;an Pennell/
Consultant psychiatrist
#troud, Gloucestershire, =8
7end response to
0ournal:
Ie: Ie: Conversion
Fysteria and Fypnotic
Paralysis: <he Jature
o. their
Jeurophysiolo,ical
7imlarity
; cannot o..er a scienti.ic response to +r @ale8s letter/ -ut a
personal eAperience may -e o. interest. +urin, my psychiatric
trainin,/ ; attended a course in -asic hypnosis/ part o. the
content o. which was to eAperience a li,ht hypnotic trance/ in
which one arm would move as i. o. its own accord. <he
eAperience was weird/ with me sensin, my arm movin, without
any intent .rom me/ as i. it was a .orei,n -ody. 6t the same
time/ ; remained .ully aware that it must have -een my motor
strip sendin, impulses to my alpha motor neurones to achieve
the movement. <he similarities to supposed conversion
symptoms struc* me .orce.ully at the time/ althou,h the
di..erence was the retention o. .ull conscious awareness o.
what was ,oin, on. ; thus -elieve in the potential reality o.
conversion symptoms/ althou,h ; too have no way o.
distin,uishin, them .rom malin,erin, in individual patients.
"he neurolo!y of hysteric conversion 8 Rune 2000
6 Chaudhuri/
Clinical 7enior 'ecturer in <he title o. this editorial commentary was promisin, -ut the
54
Jeurolo,y
=niversity of Glasgow
7end response to
0ournal:
Ie: <he neurolo,y o.
hysteric conversion
content did not o..er us much new in.ormation. 6s a
neurolo,ist/ ; have always wondered why Charcot/who used
hypnosis to relieve conversion symptoms/ -elieved that the
acute coversion reaction had a neurolo,ical -asis. ;ncidentally/
it was Charcot who interested 5reud and Ranet in the study o.
this disorder and the term SconversionS was .irst used -y 5reud
and his students who eAplained the symptoms o. hysterical
conversion as a process in which the Spsychic ener,yS o. the
unconscious mental con.licts was converted into the physical
symptoms o. hysterical reaction "e.,. paralysis/ -lindness etc.$.
6s a concept/ hysterical conversion is o. interest to idle
neurolo,ists li*e mysel. -ecause it provides a possi-le
template where SmindS can actually alter the neuronal
in.ormation processin,. (e have enou,h evidence that -rain is
a-le to suppress in.ormation mismatch -etween contrastin,
physical inputs: am-lyopia eA anopsia is the -est eAample/ -ut
anyone .amiliar with Pro.essor Iamachandran8s wor* ".amous
.or his SmirrorS eAperiments and studies on the phantom pain $
will -e aware that visual inputs can alter physical appreciation
o. sensations and possi-ly motor .unctions. Current data on the
.unctional neuroima,in, o. hysteric conversion is important -ut
is an incomplete piece o. evidence ; .ully a,ree with +r. vale
that the anterior cin,uale corteA may not -e the only area
involved in the mismatch o. in.ormation arrivin, .rom the
eAternal"SphysicalS$ and the internal"SmentalS$ environment.
5or decades/ hysteric conversion has -een the .avourite
escape -utton o. the neurolo,ist seein, a patient "usually a
woman$with normal dia,nostic tests and un.amiliar symptoms.
<here are some lon,itudinal studies that su,,est that some o.
these patients may eventually develop or,anic diseases
"usually vascular and demyelination$. Fowever/ there are very
.ew studies that have tried to address methodically the e..ect o.
social/educational and cultural .orces on the -rain .unction. ;n
an ele,ant study usin, .unctional neuroima,in, to compare the
literate and illterate Portu,ese women/ it was shown that the
illiterate women demonstrated in.erior a-ility in the lan,ua,e
processin, tas*"repetition o. nonsense words$ associated with
55
a .ailure o. the activation o. the anterior cin,uale corteA despite
havin, e4ual intelli,ence and social .unction "!$. <his
o-servation con.irmed that learnin, to read and write durin,
childhood may .undamentally chan,e the .unctional
neuroanatomy o. -rain and could in.luence the -rain8s
processin, o. co,nitive tas*s "e.,. response to stress$ as well.
(here do we ,o .rom hereK 5irstly/ it is time that wider and
more methodical research should -e underta*en to understand
the neuro-iolo,y o. hysterical conversion disorder. 7econdly/
physicians must learn to consider hysterical conversion as a
tan,i-le/ de.inite illness and not to dismiss the patient as a
S.a*er o. illnessS/ a view that/ un.ortunately/ is still prevalent in
practice.
5inally/ a small correction. <he authors have su,,ested that
chronic .ati,ue syndrome "C57$ -elon,s to the ,roup o.
somato.orm disorders/ this is entirely incorrect. ;t is also less
than true that co,nitive -ehavioural therapy is an e..ective
treatment .or C57.
Ie.erence
!.Castro%Caldas 6/ Petersson M?/ Ieis 6/ 7tone%3lander 7/
;n,var ?. <he illiterate -rain learnin, to read and write durin,
childhood in.luences the .unctional or,aniBation o. the -rain.
2rain !HH8 !2!: !05# %E#.
21stract
-ar O( 12yP> 7( D#*an /( />tP <
;h !r,alnc #$ c#n,rsi#n sy"!t#"s in 4#"n $r#" a *nral ;ur2ish !#!ulati#n.
FJ#urnal 1rticlG
Psychosomatics 2009 Jan-Feb; 50(!"50-#$
*23KD:&.ED= C#n,rsi#n sy"!t#"s ha, hist#rically : sn t# : rlat' t#
'iss#ciati, 'is#r'rs an' arly trau"a.
&*A73T);7= ;his stu'y s#u*ht t# 'tr"in th !r,alnc #$ c#n,rsi#n sy"!t#"s
a"#n* 4#"n in th *nral ;ur2ish !#!ulati#n.
M7T4&D= Partici!ants (9Q628) 4r a'"inistr' ;h Diss#ciati, Dis#r'rs %ntr,i4
-ch'ul( th 5#r'rlin Prs#nality Dis#r'r scti#n #$ th -tructur' Clinical %ntr,i4 $#r
D-&-%%%-8 Prs#nality Dis#r'rs( an' th P;-D &#'ul #$ th -tructur' Clinical %ntr,i4
$#r D-&-%%%-8; 48.7R #$ !artici!ants ha' a li$ti" hist#ry #$ a c#n,rsi#n sy"!t#". ;hy
r!#rt' ,ari#us ty!s #$ chil'h##' a:us an' n*lct "#r $rAuntly than n#nc#n,rsi#n
su:@cts.
5!
:7/.6T/= .i$ti" 'ia*n#sis #$ "a@#r '!rssi#n( 'iss#ciati, 'is#r'r( an' chil'h##'
!hysical a:us !r'ict' a c#n,rsi#n sy"!t#". <$$cts #$ chil'h##' n*lct an' "#ti#nal
an' sBual a:us a"#n* su:@cts 4ith c#n,rsi#n sy"!t#"s 4r "'iat' :y c#"#r:i'
li$ti" 'ia*n#sis #$ "a@#r '!rssi#n an' 'iss#ciati, 'is#r'rs.
3&E36./)&E= ;h auth#rs su**st r,isi#ns t# th D-&-O r*ar'in* c#n,rsi#n an'
s#"ati>ati#n 'is#r'rs.
?ncyclopedia of *ental "isorders 77 Cr+"el
$onversion disorder
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Definition
3onversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders, 4th
?dition, Text <evision, also 2nown as the 3SM-2;-4&,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 $omatoform disorders are mar2ed 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
3SM-2;-4&classifies conversion disorder as one of the somatoform disorders, first classified as a
group of mental disorders by the 3SM 222in 1:5' )ther terms that are sometimes used for
conversion disorder include pseudoneurologic syndrome, hysterical neurosis, and psychogenic
disorder
3onversion disorder is a ma1or reason for visits to primary care practitioners )ne study of health
care utilization estimates that 25X62G of office visits to primary care doctors involve
psychological distress that ta2es the form of somatic /physical0 symptoms &nother study
56
estimates that at least 1'G of all medical treatments and diagnostic services are ordered for
patients with no evidence of organic disease 3onversion disorder carries a high economic price
tag #atients who convert their emotional problems into physical symptoms spend nine times as
much for health care as people who do not somatosizeF and 52G of adults with conversion
disorder stop wor2ing because of their symptoms The annual bill for conversion disorder in the
Bnited $tates comes to ]2' billion, not counting absenteeism from wor2 and disability payments
Description
3onversion disorder has a complicated history that helps to explain the number of different
names for it Two eminent neurologists of the nineteenth century, (ean+*artin 3harcot in #aris
and (osef Creuer in -ienna were investigating what was then called hysteria, a disorder primarily
affecting women /the term EhysteriaE comes from the @ree2 word for uterus or womb0 Aomen
diagnosed with hysteria had freDuent emotional outbursts and a variety of neurologic symptoms,
including paralysis, fainting spells, convulsions, and temporary loss of sight or hearing #ierre
(anet /one of 3harcot;s students0, and Creuer independently came to the same conclusion about
the cause of hysteriaRthat it resulted from psychological trauma (anet, in fact, coined the term
EdissociationE 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 Ecombat
neurosisE in Aorld Aar , /1:14+1:150 and Aorld Aar ,, /1:3:+1:450 *any of the symptoms
observed in Eshell+shoc2edE soldiers were identical to those of EhystericalE women Two of the
techniDues still used in the treatment of conversion disorderRhypnosis and narcotherapyRwere
introduced as therapies for combat veterans The various terms used by successive editions of the
3SMand the 2C3/the ?uropean eDuivalent of 3SM0 for conversion disorder reflect its association
with hysteria and dissociation The first edition of the 3SM/1:520 used the term Econversion
reactionE 3SM-22/1:!50 called the disorder Ehysterical neurosis /conversion type0,E 3SM-
222/1:5'0, 3SM-222-&/1:560, and 3SM-2;/1::40 have all used the term Econversion disorderE
,3"+1' refers to it as Edissociative /conversion0 disorderE
3SM-2;-4&/2'''0 specifies six criteria for the dia3nosis of conversion disorder They are7
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 fa2ed or produced intentionally
The symptom cannot be fully explained as the result of a general medical disorder,
substance inta2e, 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 reDuire 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
55
3SM-2;lists four subtypes of conversion disorder7 conversion disorder with motor symptom or
deficitF with sensory symptom or deficitF with seizures or convulsionsF and with mixed
presentation
&lthough conversion disorder is most commonly found in individuals, it sometimes occurs in
groups )ne such instance occurred in 1::6 in a group of three young men and six adolescent
women of the ?mbera, an indigenous tribe in 3olombia 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
&nother example of group conversion disorder occurred in ,ran in 1::2 Ten girls out of a
classroom of 2! became unable to wal2 or move normally following tetanus inoculations
&lthough the local physicians were able to treat the girls successfully, public health programs to
immunize people against tetanus suffered an immediate negative impact )ne 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 )ne psychiatrist has defined the symptoms as Ea code that conceals the message from
the sender as well as from the receiverE
Two terms that are used in connection with the causes of conversion disorder are primary gain
and secondary gain #rimary gain refers to the lessening of the anxiety and communication of the
unconscious wish that the patient derives from the symptom/s0 $econdary gain refers to the
interference with daily tas2s, removal from the uncomfortable situation, or increased attention
from significant others that the patient obtains as a result of the symptom/s0
#hysical, emotional, or sexual abuse can be a contributing cause of conversion disorder in both
adults and children ,n a study of 34 children who developed pseudoseizures, 32G had a history
of depression or sexual abuse, and 44G had recently experienced a parental divorce, death, or
violent Duarrel ,n the adult population, conversion disorder may be associated with mobbing, a
term that originated among ?uropean psychiatrists and industrial psychologists to describe
psychological abuse in the wor2place )ne &merican woman who Duit her 1ob because of
mobbing was unable to wal2 for several months &dult males sometimes develop conversion
disorder during military basic training 3onversion disorder may also develop in adults as a long+
delayed after+effect of childhood abuse & 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
5:
Symptoms
,n general, symptoms of conversion disorder are not under the patient;s conscious control, and
are freDuently mysterious and frightening to the patient The symptoms usually have an acute
onset, but sometimes worsen gradually
The most freDuent forms of conversion disorder in Aestern countries include7
#seudoparalysis ,n pseudoparalysis, the patient loses the use of half of his9her body or of
a single limb The wea2ness does not follow anatomical patterns and is often inconsistent
upon repeat examination
#seudosensory syndromes #atients with these syndromes often complain of numbness or
lac2 of sensation in various parts of their bodies The loss of sensation typically follows
the patient;s notion of their anatomy, rather than 2nown characteristics of the human
nervous system
#seudoseizures These are the most difficult symptoms of conversion disorder to
distinguish from their organic eDuivalents Cetween 5G and 35G of patients with
pseudoseizures also have epilepsy ?lectroencephalograms /??@s0 or measurement of
serum prolactin levels, are useful in distinguishing pseudoseizures from epileptic
seizures
#seudocoma #seudocoma is also difficult to diagnose Cecause true coma may indicate a
life+threatening condition, patients must be given standard treatments for coma until the
diagnosis can be established
#sychogenic movement disorders These can mimic myoclonus, par2insonism, dystonia,
dys2inesia, and tremor "octors 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
#seudoblindness #seudoblindness is one of the most common forms of conversion
disorder related to vision #lacing 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
#seudodiplopia #seudodiplopia, or seeing double, can usually be diagnosed by
examining the patient;s eyes
#seudoptosis #tosis, or drooping of the upper eyelid, is a common symptom of
myasthenia gravis and a few other disorders $ome people can cause their eyelids to
droop voluntarily with practice The diagnosis can be made on the basis of the eyebrowF
in true ptosis, the eyebrows are lifted, whereas in pseudoptosis they are lowered
.ysterical aphonia &phonia refers to loss of the ability to produce sounds ,n hysterical
aphonia, the patient;s cough and whisper are normal, and examination of the throat
reveals normal movement of the vocal cords
#sychiatrists wor2ing in various parts of the *iddle ?ast and &sia report that the symptoms of
conversion disorder as listed by 3SM-2;and ,3"+1' do not fit well with the symptoms of the
disorder most freDuently encountered in their patient populations
:'
Demograp$ics
The lifetime prevalence rates of conversion disorder in the general B$ population are estimated
to fall between 11 and 3'' per 1'',''' people The differences in the estimates reflect
differences in the method of diagnosis as well as some regional population differences ,n terms
of clinical populations, conversion disorder is diagnosed in 5GX14G of general hospital patientsF
1GX3G of outpatient referrals to psychiatristsF and 5GX25G of psychiatric outpatients
&mong adults, women diagnosed with conversion disorder outnumber men by a 271 to 1'71
ratioF among children, however, the gender ratio is closer to 171 %ess educated people and those
of lower socioeconomic status are more li2ely to develop conversion disorderF race by itself does
not appear to be a factor There is, however, a ma1or difference between the populations of
developing and developed countriesF in developing countries, the prevalence of conversion
disorder may run as high as 31G
Diagnosis
3onversion 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 4ewer techniDues of diagnostic
imaging have helped to lower the rate of medical errors
Diagnostic issues
"iagnosis of conversion disorder is complicated by its coexistence with physical illness in as
many as !'G of patients &lternatively 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 ima3in3
studies that may be useful, and appropriate laboratory tests The doctor will also ta2e a thorough
patient history that will include the presence of recent stressors in the patient;s life, as well as a
history of abuse 3hildren and adolescents are usually as2ed about their school experiencesF one
Duestion they are as2ed is whether a recent change of school or an experience related to school
may have intensified academic pressure
,n 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 EparalyzedE arm is dropped over the patient;s face ,n conversion
disorder, the arm will not stri2e the face )ther tests include applying a mildly painful stimulus
to a Ewea2E or EnumbE part of the body The patient;s pulse rate will typically rise in cases of
conversion disorder, and he or she will usually pull bac2 the limb that is being touched
Factors suggesting a diagnosis of conversion disorder
The doctor can also use a list of factors 2nown to be associated with conversion disorder to
assess the li2elihood that a specific patient may have the disorder7
:1
&ge 3onversion disorder is rarely seen in children younger than six years or adults over
35 years
$ex The female to male ratio for the disorder ranges between 271 and 1'71 ,t is thought
that higher rates of conversion disorder in women may reflect the greater vulnerability of
females to abuse
<esidence #eople who live in rural areas are more li2ely to develop conversion disorder
than those who live in cities
%evel of education 3onversion disorder occurs less often among sophisticated or highly
educated people
8amily history 3hildren sometimes develop conversion disorder from observing their
parents; reactions to stressors This process is 2nown as social modelin3
& recent stressful change or event in the patient;s life
&n additional feature suggesting conversion disorder is the presence of la elle indiff#rence The
8rench phrase refers to an attitude of relative unconcern on the patient;s part about the symptoms
or their implications "a elle indiff#renceis, however, much more common in adults with
conversion disorder than in children or adolescents #atients in these younger age groups are
much more li2ely to react to their symptoms with fear or hopelessness
,edical conditions t$at mimic conversion symptoms
,t 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 diagnosis7
multiple sclerosis /blindness resulting from optic neuritis0
myasthenia gravis /muscle wea2ness0
periodic paralysis /muscle wea2ness0
myopathies /muscle wea2ness0
polymyositis /muscle wea2ness0
@uillain+Carr^ syndrome /motor and sensory symptoms0
Treatments
#atients diagnosed with conversion disorder freDuently benefit from a team approach to
treatment and from a combination of treatment modalities & 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
,edications
Ahile 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
Psyc$ot$erapy
:2
2sychodynamic psychotherapy is sometimes used with children and adolescents to help them
gain insight into their symptoms 3ognitive behavioral approaches have also been tried, with
good results /amily therapy is often recommended for younger patients whose symptoms may
be related to family dysfunction 9roup therapy appears to be particularly useful in helping
adolescents to learn social s2ills and coping strategies, and to decrease their dependency on their
families
Inpatient treatment
(ospitalization is sometimes recommended for children with conversion disorders who are not
helped by outpatient treatment ,npatient 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
&lternative and complementary therapies that have been shown to be helpful in the treatment of
conversion disorder include hypnosis, relaxation techniDues, visualization, and biofeedbac<
Prognosis
The prognosis for recovery from conversion disorder is highly favorable #atients 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 )f patients hospitalized for the disorder,
over half recover within two wee2s Cetween 2'G and 25G will relapse within a year The
individual symptoms of conversion disorder are usually self+limited and do not lead to lasting
disabilitiesF 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 li2ely to continue to decline with rising levels
of formal education and the spread of basic information about human psychology #revention of
conversion disorder in children and adolescents depends on better strategies for preventing
abuse
Resources
8==KS
&merican #sychiatric &ssociation 3ia)nostic and Statistical Manual of Mental 3isorders.4th
edition, text revised Aashington, "37 &merican #sychiatric &ssociation,2'''
:3
E3onversion "isorderE $ection 15, 3hapter 15! in4he Merc+ Manual of 3ia)nosis and 4hera9y,
edited by *ar2 . Ceers, *", and <obert Cer2ow, *" Ahitehouse $tation, 4(7 *erc2
<esearch %aboratories, 1:::
"avenport, 4oa, #h", <uth " $chwartz, and @ail # ?lliott Moin)1 <motional Ause in the
American =or+9lace. &mes, ,&7 3ivil $ociety #ublishing, 1:::
3orland-s 'oc+et Medical 3ictionary.25th edition #hiladelphia7 A C $aunders 3ompany,
1::5
.erman, (udith, *" 4rauma and &eco.ery.2nd edition, revised 4ew Oor27 Casic Coo2s, 1::6
#elletier, Lenneth <, *" E$ound *ind, $ound Cody7 *indCody *edicine 3omes of &geE
3hapter 2 in 4he (est Alternati.e Medicine. 4ew Oor27 $imon and $chuster, 2''2
Aorld .ealth )rganization /A.)0 4he 2C3-1/ Classification of Mental and (eha.ioural
3isorders. @eneva7 A.), 1::2
P(RI=DI$A>S
&l+$harbati, * *, 4 -iernes, & &l+.ussaini, and others E& 3ase of Cilaterial #tosis with
Bnsteady @ait7 $uggestibility and 3ulture in 3onversion "isorderE 2nternational %ournal of
'sychiatry in Medicine31 /2''107 225+232
3ampo, (ohn - E4egative <einforcement and Cehavioral *anagement of 3onversion "isorderE
%ournal of the American Academy of Child and Adolescent 'sychiatry 3: /(une 2'''07 656+6:'
3rimlis2, .elen %, and others E$later <evisited7 !+Oear 8ollow+Bp of #atients with *edically
Bnexplained *otor $ymptomsE (ritish Medical %ournal31! /8ebruary 21, 1::507 552+55!
@lic2, T ., T # Aor2man, $ - @aufberg E$uspected 3onversion "isorder7 8oreseeable <is2s
and &voidable ?rrorsE Academy of <mer)ency Medicine6 /4ovember 2'''07 1262+1266
.aghighi, $ $, and $ *eyer E#sychogenic #araplegia in a #atient with 4ormal
?lectrophysiologic 8indingsE S9inal Cord3: /"ecember 2''107 !!4+!!6
%angmann, &, $ %indner, 4 Lriechbaum E8unctional <eduction of -ision $ymptomatic of a
3onversion <eaction in a #aediatric #opulation =in @erman>E Klinische Monatslatter
Au)enheil+unde215 /)ctober 2''107 !66+!51
*eyers, Timothy (, Cruce A (afe2, &rlen " *eyers E<ecurrent #sychogenic 3oma 8ollowing
Tracheal $tenosis <epairE Archi.es of >tolaryn)olo)y?*ead & Nec+ Sur)ery125 /4ovember
1:::07 12!6
:4
*oene, 8 3, ? . %andberg, L & .oogduin, and others E)rganic $yndromes "iagnosed as
3onversion "isorder7 ,dentification and 8reDuency in a $tudy of 55 #atientsE %ournal of
'sychosomatic &esearch4: /(uly 2'''07 6+12
*ori, $, $ 8u1ieda, T Oamamoto, and others E#sychogenic .earing %oss with #anic &nxiety
&ttac2 &fter the )nset of &cute ,nner ?ar "isorderE >&" %ournal of >torhinolaryn)olo)y and
&elated S9ecialties!4 /(anuary+8ebruary 2''207 41+44
#ineros, *arion, "iego <osselli, 3laudia 3alderon E&n ?pidemic of 3ollective 3onversion and
"issociation "isorder in an ,ndigenous @roup of 3olombia7 ,ts <elation to 3ultural 3hangeE
Social Science & Medicine 4! /(une 1::507 1425+1425
$halbani, &ziz, and *arwan 4 $abbagh E#seudoneurologic $yndromes7 <ecognition and
"iagnosesE American ,amily 'hysician56 /*ay 15, 1::507 2'6+212
$oares, 4eel2amal, and %inda @rossman E$omatoform "isorder7 3onversionE eMedicine
%ournal2 /$eptember 14, 2''10
$yed, ? B, and others E3onversion "isorder7 "ifficulties in "iagnosis Bsing "$*+,-9,3"+
1'E %ournal of the 'a+istani Medical Association51 /&pril 2''107 143+145
Ayllie, ?laine, (ohn # @lazer, $elim Cenbadis, and others E#sychiatric 8eatures of 3hildren and
&dults with #seudoseizuresE Archi.es of 'ediatrics & Adolescent Medicine153 /*arch 1:::07
244+245
Oasamy, * T, & Cahramnezhad, . Yiaaddini E#ost+vaccination *ass #sychogenic ,llness in
an ,ranian <ural $choolE <astern Mediterranean *ealth %ournal5 /(uly 1:::07 61'+61!
=R*A#IEA"I=#S
&merican &cademy of 3hild and &dolescent #sychiatry 3!15 Aisconsin &venue, 4A,
Aashington, "3 2''1!+3''6/2'20 :!!+63'' 8ax7 /2'20 :!!+25:1 _wwwaacaporg`
4ational ,nstitute of *ental .ealth !''1 ?xecutive Coulevard, <oom 5154, *$3 :!!3,
Cethesda, *" 2'5:2+:!!3 /3'10 443+4513 _wwwnimhnihgov`
<ebecca ( 8rey, #h"
Cross#cultural 2sychiatry
,ntroduction 1+2
3rucial 3linical 3onsiderations7
,ncorporating 3ultural 3ompetency into #sychiatric &ssessment 3
)utline for 3ultural formulation of psychiatric disorders 4
:5
3ultural context and the presentation of psychiatric disorders 6+5
3ulture+bound syndromes :
@lossary of culture+bound syndromes :+1'
Introduction
3urrently, multitudes of people live in the Bnited $tates, bringing more diversity with each day
.ispanics and &frican &mericans account for about 12G of those who reside in the B$ &sians
comprise 33G and 23G are 4ative ,ndian, &las2a 4ative, #acific ,slanders, and those of two or
more races /B$ 3ensus Cureau0 ,t is pro1ected that by 2'5', roughly 5'G of the &merican
population will be non+.ispanic Ahite while .ispanics will be amount to about 244G, &frican
&mericans comprising14!G, &sians 5'G, and 4ative &merican, &las2a 4ative, #acific
,slanders, and those of two or more races amounting to 53G /B$ 3ensus Cureau0 &merica is
Duic2ly becoming more diverse 4ot only does ethnic and racial diversity exist but so does
diversity in gender, sexual preference, geographic location, age, occupation, marital status,
socioeconomic status, education, migration history, and religious and spiritual affiliation Ahile
this country has thrived on the variety of peoples that inhabit it, *ental .ealth care providers
have a particularly challenging role of providing care that is culturally competent The issue of
culturally competent care is so important that in 2''1, the )ffice of the $urgeon @eneral released
in a supplement to the <eport on *ental .ealth entitled a*ental .ealth7 3ulture, <ace, and
?thnicityb discussing the growing crisis of inadeDuate mental health services for the countryIs
ethnic minorities
1
Ahen compared to Ahites, minorities have less access to and availability of
mental health services They are less li2ely to receive services and when they do receive services,
those services are li2ely of poorer Duality *inorities are also underrepresented in mental health
research
,n order to better understand 3ultural psychiatry, it is important to understand some basic
definitions 3ulturally bound syndromes are defined in a separate section at the end of this
chapter
Culture & set of meanings, behavioral norms, and values used by members of a particular
society as they construct their uniDue view of the world These values or reference points include
areas such as social relationships, language, nonverbal expression of thoughts and emotions,
religious beliefs, moral thought, technology, and financial philosophy 3ulture is not a static
notion but one that changes as it is taught by one generation to the next
2

ace Bsed to refer to a group of people who supposedly share similar physiologic, biologic, and
genetic underpinnings
2
eg /&frican, 3aucasian0
.thnicity $ub1ective sense of belonging to a group of people with a common origin and with
shared social and cultural beliefs and practices
2
These people share a common history and
origin ,t may imply nationality, geographic location, and religious beliefs /eg -ietnamese
&merican, <ussian (ewish, and ?thiopian0
3

Cultural 2sychiatry The discipline that deals with the description, definition, assessment, and
management of all psychiatric conditions as they reflect and are sub1ected to the influence of
:!
cultural factors in a biopsychosocial context while using concepts and instruments from social
and biological sciences to advance a full understanding of psychopathology and its treatment
2

,n order to better evaluate the effect that culture has on a patient and their illness ,t is not enough
to have factual 2nowledge about a patientIs culture without having it in context of how the
people view themselves in it and its role in their lives The 3ultural 8ormulation is a tool, found
in the "$*+,-+T<, identifies five ma1or areas crucial in evaluating the cultural influences on
mental health *ore details about the 3ultural 8ormulation are provided later in this chapter
,t is also imperative is to 2now and understand Cultural Bound Syndromes Bnli2e "$*
diagnoses that can be found worldwide, such syndromes are particular to different localities or
ethnic groups $uch culturally bound syndromes may or may not correspond to diagnostic
categories in the "$*+,-+T< ,t is important to 2now such syndromes in order for clinicians to
ma2e a culturally appropriate diagnosis The "$* lists several of these syndromes, many of
which can be found in the glossary at the end of this chapter
1 http799wwwsurgeongeneralgov9library9mentalhealth9cre9execsummary+2html
2 @roup for the &dvancement of #sychiatry7 3ultural &ssessment in 3linical #sychiatry
Aashington, "3, &merican #sychiatry #ublishing, 2''2
3 Ton . J %im <8 aThe &ssessment of 3ulturally "iverse ,ndividualsb7 Clinical Manual of
Cultural 'sychiatry &##,, Aashington, "3, 2''!
Incorporatin3 Cultural Competency into the 2sychiatric Assessment
"o not assume anything about the patientsI cultural identities
1

Bsing an ,nterpreter X clinicians should use a non+family interpreter if the language is not the
clinicianIs native language This includes sign language
*any nuances of speech and culture within speech /eg slang words0 can be missed, and such
nuances are important to understanding the complete patient, especially in psychiatry &s such all
efforts must be underta2en to find an appropriate interpreter The following websites can be
useful in obtaining an interpreter7 %anguagefoncom, certifiedlanguagescom, 1+5''+
translatecom, languagelinecom
&lso, a family member could be utilized as a last resort in urgent situations only ,n any case,
patients may not be able to discuss their issues because the problems may be too traumatic or
embarrassing to discuss with the translator present or there may be fear of repercussions if the
interpreter is the 2nown or un2nown perpetrator of domestic violence
Consider the culture
?licit9encourage patients to describe what part of identity is important to them while explaining
your own perspectives of illness /Ton J %im 140
&ssess symptoms that patients are comfortable expressing to create initial rapport 8or
examples, in many cultures, patients may be more comfortable expressing somatic complaints
than psychiatric complaints /Ton J %im 150
:6
,n order to better understand the cultural context of the patientIs illness, one can as2 a.ow
would your friends, family, community, or those who 2now you best /and9or are most li2e you0
explain what is happeningKb /3arabello et al 2:! X 2:60
&lways inDuire about patientIs previous and current level of functioning
1 3araballo &, .amid ., %ee (<, *cUuery (, <ho O, Lramer ?(, %im <8, J %u 8 a& <esidentIs
@uide to the 3ultural 8ormulationb7 Clinical Manual of Cultural 'sychiatry &##,, Aashington,
"3, 2''!
8utline for Cultural formulation of psychiatric disorders
1 3ultural ,dentity
?thnic or cultural reference group /including sexual orientation,
socioeconomic status, religion, relationship status, age0
"egree of involvement in culture of origin
"egree of involvement in host culture
&spects of identity that are important to them
*igration history /if applicable0 X reasons for migration, losses, trauma, J
previous role within family J society
%anguage abilities, use J preferences
2 3ultural ?xplanation of the ,ndividualsI ,llness
#redominant idioms of distress
*eaning of perceived severity of symptoms in relation to social norms
#erceived causes or explanatory models to explain illness X how would
family9friend9community9those who 2now you best and9or most li2e you
explain what is occurring
3urrent preferences for and past experiences of professional care
3 3ultural 8actors <elated to #sychosocial, ?nvironmental and 8unctionality 8actors
$ocial stressors
$ocial supports X role of religion and 2in networ2s, identify who is a ma1or
support for the patient
%evels of functioning and disability Xviewed by patient, family J community
/previous and current0
?nvironment X level of acceptance, respect felt in this country by patient
J family, special9sacred places, if a community that he9she can identify
with has been found /J if this is important for the patient to find one0
4 3ultural ?lements of the <elationship between the ,ndividual and the 3linician
?xamined culture, social status, differences, languages
*aintain ongoing assessment
Ceware of transference and countertransference issues
3onsider the patientIs motivation for see2ing treatment
3onsider need for cultural consultation
:5
5 )verall 3ultural &ssessment for "iagnosis and 3are X &ssess cultural considerations and its
influence on comprehensive diagnosis and care
[ Cultural ,ormulation com9iled from the follo$in) sources1 3SM 2;-4&, Clinical Manual of
Cultural 'sychiatry, & :rou9 for the Ad.ancement of 'sychiatry1 Cultural Assessment in
Clinical 'sychiatry
Cultural conte;t and the presentation of psychiatric disorders
Schizophrenia $ome apparently psychotic experiences may be normal when viewed within a
cultural context This applies to delusions /eg belief in magic, spirits, or demons0 and
hallucinations /eg seeing HaurasIor divine entities, hearing @odIs voice0 )ther evidence of
apparent psychosis, such as disorganized speech, may actually reflect local variations in
language syntax, or the fact that the person is not completely fluent in the language used by the
interviewer "ifferences in non+verbal communication /eg eye contact, facial expression, body
language0 may also be misinterpreted /what is expected in one culture may be rude in another
culture0 .istorically there has been a tendency in the BL and B$ to diagnose schizophrenia
more readily in certain cultural groups /eg &fro+3aribbeans0 This probably does not reflect
differences in the incidence of schizophrenia, but rather a lac2 of understanding of cultural
differences $ome symptoms of schizophrenia /eg catatonia0 are more common in non+Aestern
countries, and even between Aestern countries the diagnosis of brief psychoses varies /eg for
bouf^e deliriante+ see end of chapter for details0
'ania )ften used colloDuially to mean Hchanges in normal behaviorI, rather than its "$*
definition ,t may be difficult to distinguish periods of frenzied activity /eg in amo+Rsee end of
chapter0 from increased activity, energy, and reduced need for sleep in a manic episode
Depression 3ultural expressions of depressive symptoms vary across populations ,n some
cultures there is greater emphasis on somatic terms eg HnervesI or HheadachesI /*editerranean
cultures0F Hproblems of the heartI /*iddle ?ast0F HimbalanceI, Hwea2nessI, or HtirednessI /3hina
and &sia0 This often ma2es the use of Aestern diagnostic classifications difficult, as symptoms
may cross diagnostic boundaries /eg mood, anxiety, somatoform disorders0 ?Dually difficult
may be the interpretation of culturally normal explanations for symptom causationRwhich may
appear delusional /eg spirit possession0, or associated somatic symptoms that need to be
distinguished from actual hallucinations
An;iety and stress#related disorders
A3oraphobia $ocial sanctions against members of certain populations /eg women0 appearing
in public may be confused with agoraphobic symptoms
2anic Attac<s ,n some cultures these may be interpreted as evidence of magic or witchcraft
/particularly when they come Hout of the blueI0
8CD <eligious and cultural beliefs influence the content of obsessions and nature of
compulsions ,t may be difficult to assess the significance of ritualistic behaviors unless the
clinician has 2nowledge of cultural customs
2TSD ,mmigrants may have emigrated to escape military conflict or particularly harsh regimes
They may have had experience of significant traumatic events, but may be unwilling /or unable0
to discuss them because of language problems or fears of being sent bac2
::
Somatization Disorder 3ommon types of somatic symptoms vary across cultures /and genders
within cultures0 These reflect the principle concerns of the population /or individual0 eg
worms9insects in the scalp9 under the s2inRseen in $outh+?ast &sia and &fricaF concern about
semen lossRseen in ,ndia /see 3hat0 and 3hina /see Shen+ui0
Conversion and Dissociative Disorders *ore common in rural populations and Hless educatedI
societies, and may be culturally normal 3ertain religious rituals involve alteration in
consciousness /including trance states0, beliefs in spirit possession, and varieties of socially
sanctioned behaviors that could be viewed as conversion or dissociative disorders /eg fallin)
out, s9ell, @ar0 H<unningI subtypes of culture+bound syndromes have symptoms that would meet
criteria for dissociative fugue
Anore;ia Nervosa 3ultural influences that promote thinness as the ideal of body shape are
more prevalent in Aestern societies with an abundance of food ,mmigrants from other cultural
bac2grounds may assimilate this ideal, or may present with primary symptoms other than
disturbed body image and fear of weight gain /eg stomach pains, lac2 of en1oyment of food0
Alcohol and Substance 'isuse 3ultural factors heavily influence the availability, patterns of
use, attitudes about, and even the physiological or behavioral effects of alcohol and other
substances
Alcohol $ocial, family, and religious attitudes towards the use of alcohol may all influence
patterns of use and the li2elihood of developing alcohol+related problems &lthough it is difficult
to separate cause from effect, low levels of education, unemployment, and low social status are
all associated with increased misuse of alcohol ,n some populations /eg (apanese and 3hinese0
up to 5'G may have a deficiency of aldehyde dehydrogenase /complete absence in 1'G0, with
low rates of alcohol problems in these populations because the physiological effects of
consuming alcohol may be extremely unpleasant /eg flushing and palpitations due to
accumulation of acetylaldehyde0 .ow individuals behave when intoxicated may also be
culturally determined, eg aggressive and antisocial behavior /typified by Hfootball hooligansI0
not seen in cultures where alcohol is more of a Hsocial lubricantI, despite levels of alcohol
consumption being similar
8ther substances Bse of hallucinogens and other drugs may be culturally acceptable when part
of religious rituals /eg peyote in the 4ative &merican 3hurch, cannabis in <astafarianism0
?Dually, secular movements, typified by the hippie movements of the !'s and 6's, or more
recently the Hdance cultureI, provide a context in which psychedelic experiences /eg induced by
%$" or *"*&0 may be experienced without any adverse social sanctions
Culture#bound syndromes
3ulture+bound or culture+specific syndromes cover an extensive range of disorders occurring in
particular localities or ethnic groups The behavioral manifestations or sub1ective experiences
particular to these disorders may or may not correspond to diagnostic categories in "$*+,-+T<
or ,3"+1' They are usually considered to be illnesses and generally have local names They also
include culturally accepted idioms or explanatory mechanisms of illness that differ from Aestern
idioms and outside of their cultural setting may be mista2en for psychosis &wareness of culture+
bound syndromes is important to allow psychiatrists and physicians to ma2e culturally
appropriate diagnoses
9lossary of culture#bound syndromes
1''
Amafufunyane see ufufunyane below
Amo< AMalaysia, "aos, 'hili99ines, 'olynesia Bcafard or cathardC, 'a9ua Ne$ :uinea, and
'uerto &ico Bmal de peleaC, Dnited States Bgoing postalC, and amon) the Na.aEo BiichaaCF X
&mo2 is the *alayan word meaning ato engage furiously in battleb and is typically prevalent
only in males ,t is often precipitated by a perceived slight or insult, which is followed by a
sudden outburst of wild rage causing the person to run madly about with a weapon and attac2 or
2ill people and animals before being overpowered and sometimes committing suicide )ften
preceded by a period of preoccupation, brooding, and mild depression &fterwards, the person
feels exhausted and amnesic .e9she eventually returns to premorbid state &n attac2 can last for
a few hours, and may be attributed to magical possession by demons and evil spirits $ome
instances of amo2 may occur during a brief psychotic episode or constitute the onset or an
exacerbation of a chronic psychotic process
Bilis and c=lera /also referred to as muina X %atino @roups0 X Bnderlying cause of these
syndromes is thought to be strongly experienced anger or rage, /bilis and cclera literally translate
as abileb0 &nger is viewed among many %atino groups as a particularly powerful emotion that
can have direct effects on the body and can exacerbate existing symptoms The ma1or effects of
anger are the disturbance of core body balances /which are understood as a balance between hot
and cold valences in the body and between the material and spiritual aspects of the body0
$yndromes can include acute nervous tension, headache, trembling, screaming, stomach
disturbances, and, in more severe cases, loss of consciousness 3hronic fatigue may result from
acute episode
Bouf>e delirate /Aest &frica and .aiti0 X This 8rench term refers to a sudden outburst of
agitated and aggressive behavior, mar2ed confusion, and psychomotor excitement ,t may
sometimes be accompanied by visual and auditory hallucinations or paranoid ideation These
episodes may resemble an episode of Crief #sychotic "isorder
Curanderismo /*exican &mericans and other $panish+spea2ing people0 X 8ol2 medicine in
which the healers /curanderos =male> or curannderas =female> use a combination of herbal
infusions, dramatic healing rituals, and prayers to treat a variety of physical and psychological
symptoms including embru?o /witchcraft0, empacho /intestinal distress0, mal o?o /evil eye0,
mal puesto /hexing0, mollera ca@da, /sun2en fontanel, see below0 and susto /soul loss, see
below0
Dhat B2ndia - also jiranC, Sri "an+a Bsu!ra prameha", and China Bshen#!ueiC X & fol2
diagnostic term used to refer to severe anxiety and hypochondriacal concerns associated with the
discharge of semen, whitish discoloration of the urine, and feeling of wea2ness and exhaustion
Traditional remedies consist of herbal tonics to restore semen9humoral balance
/allin3 outABlac<in3 out /$outhern Bnited $tates and 3aribbean groups0 X ?pisodes are
preceded by feelings of dizziness or aswimmingb in the head and characterized by an
individualIs eyes being open but the person claims an inability to see The person usually hears
and understands what is occurring around him9her but feel powerless to move This may
correspond to a diagnosis of 3onversion "isorder or a "issociative "isorder
9host Sic<ness /4ative &mericans0 X & preoccupation with death and the deceased /sometimes
associated with witchcraft0 freDuently observed among members of many 4ative &merican
tribes -arious symptoms can be attributed to ghost sic2ness, including bad dreams, wea2ness,
feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of
consciousness, confusion, feeling of futility, and a sense of suffocation *ay be triggered by a
death and afflicted individuals feel that the ghost of a dead person is torturing them
1'1
(wa#byun3 /also 2nown as wool#hwa#byun30 /in Lorea as aanger syndromeb0 X &ttributed to
the suppression of anger $ymptoms include insomnia, fatigue, panic, fear of impending death,
dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains, and a
feeling of a mass in the epigastrium The belief is related to ideas of bodily imbalances caused by
anger
"oro =possible *alaysian origin, 3hinese /shu< yan3, shoo< yon3, J suo yan30, &ssam
/?in?inia bemar0, and Thailand /ro<#?oo0> X <efers to an episode of sudden and intense anxiety
that the penis /or, in females, the vulva and nipples0 will recede into the body and possibly cause
death Bsually occurs in young, single males #rodromal depersonalization usually occurs and
elaborate measure may be ta2en to prevent the genitals from retracting /eg grasping of genitals,
splints or other devices, herbal remedies, or fellatio0 #recipitants may include coitus, cold
exposure, fears concerning sexual virility, tales of people dying from the illness, and eating
spoiled food Loro at times occurs in localized epidemic forms in ?ast &sian areas This
diagnosis is included in the 3hinese 3lassification of *ental "isorders, $econd ?dition
4ata, latah Malay, Sierian )rou9s Bamura!h, ir!unii, i!ota, olan, mriachit, and men!etiC,
4hailand Bbah tschi & baah#jiC, Ainu, Sa+hlin, %a9an BimuC, and 'hili99ines Bmali#mali & silo!C
X ,n *alaysia, it is more freDuently in middle+aged women The syndrome includes
hypersensitivity to fright, often with echopraxia, echolalia, command obedience, and dissociative
or tranceli2e behavior ,t is caused by a sudden stimulus that suspends all normal activity ,t may
be a symptom of disease /eg acute psychosis, conversion9dissociative state0 or be an isolated
behavioral abnormality
4ocura /%atinos in Bnited $tates J $outh &merica0 X Bsed to refer to a severe form of chronic
psychosis The syndrome is attributed to an inherited vulnerability, to the effect of multiple life
difficulties, or to a combination of both factors $ymptoms exhibited by person with locura
include incoherence, agitation, auditory and visual hallucinations, inability to follow rules of
social interactions, unpredictability and possible violence
'ollera ca@da, Bfallen fontanel syndromeC /latino populations in the &mericas0 $een in
infants less than one year old $igns of the illness were listlessness, fever, diarrhea, and sun2en
eyes and were actually thought to be secondary to the depressed fontanel ,n fact the depressed
fontanel usually resulted from infection or malnutrition The illness was cured by curanderismo
with herbs, teas, and pastes
Nerfiza, nerves, nervios B"atino 9o9ulations in Dnited States, "atin America, <)y9t, Northern
<uro9eC BSimilar to nevra in :reeceC. 3hronic somatic, emotional, and behavioral symptoms
/eg headache, sleep problems, reduced appetite, nausea, fatigue, dizziness, par aesthesia,
anxiety, concentration difficulties, and emotional lability9distress0 *ore common in women,
associated with anger, emotional distress, low self+esteem Bsually treated with traditional herbal
teas, Hnerve pillsI, rest, isolation, and increased family support
2iblo<to, piblo<toD B'olar <s+imo $omenC GArctic hysteria8 &n acute dissociative state /lasting
about 3' min0 following the actual /or symbolic0 loss of someone or something important to the
individual Bsually mild irritability or withdrawal precedes impulsive or dangerous acts /eg
screaming, tearing off of clothes, brea2ing furniture, shouting obscenities, eating feces, or
rushing out into the snow0 *ay be followed by convulsions and coma /lasting up to 12 hours0
with associated amnesia &lthough some researchers have suggested it may be due to
hypocalcaemia tetany, it is most probably an anxiety state
1'2
Ei#3on3 psychotic reaction BChinaC G<xercise of .ital ener)y8R&n acute episode characterized
by dissociative, paranoid, or other symptoms after participation in the health+enhancing practice
of Di+gong
ootwor< B*aiti and Su-Saharan AfricaC associated syndromes1 voodoo death B*aitiC, mal
puesto or brujeira B"atin AmericaC, and he$ & variety of complaints attributed to hexing,
witchcraft, sorcery, voodoo, or the evil influence of another person $ymptoms include anxiety,
@, complaints, and fear of being poisoned or 2illed 3an result in death
San3ue dormido, BSleepin3 bloodC /3ape -erde ,slanders0 $omatic symptoms including pain,
numbness, tremor, paralysis, convulsions, blindness, and increased ris2 of heart attac2, infection,
and miscarriage
Shen?in3 shuairuo /3hina0 or neurastheniaRsymptoms include7 fatigue, irritability, poor
concentration9memory, sleep disturbance, and other somatic symptoms /dizziness, headaches,
pain, @, upset, sexual dysfunction, and other signs of autonomic dysfunction0 *ost cases would
meet criteria for depressive or anxiety disorders
Shen#<Cuei /Taiwan0, shen<ui /3hina0 $imilar to dhat and jiran /,ndia0, and su!ra prameha
/$ri %an2a0 &nxiety and panic with somatic complaints, especially sexual dysfunction
/premature e1aculation and impotence0 $ymptoms are attributed to excessive semen loss from
sexual activity or Hwhite turbid urine,I which reduces Hvital energyI ,t is viewed as a life+
threatening condition and described in areas with a 3hinese ethnic population
Shin#byun3 /Lorea0 #ossession /dissociative0 state attributed to ancestral spirits with associated
anxiety9fear and somatic complaints /generalized wea2ness, dizziness, insomnia, loss of appetite,
and @, problems0
Shin<eishitsu /(apan0 a syndrome that is manifested by obsessions, perfectionism, ambivalence,
social withdrawal, fatigue, and hypochondriasis
Spell /$outhern Bnited $tates0 & trance state in which individuals HcommunicateI with deceased
relatives or with spirits, often accompanied by brief periods of personality change ,n context,
HspellsI are culturally normal
Susto, espanto, Bma3ic fri3htC, B'eruC BSee curanderismo who treat this condition.C Also seen
in "atinos of the Dnited States, Mexico, and other CentralHSouth America. &elated syndromes1
lanti B'hili99inesC, malgri BAori)ines of AustraliaC, mogo laa BNe$ :uineaC, narahati B2ranC,
and saladera Bin re)ions around the Ama@onC. 8right or fear of loss of soul &n acute anxiety
state, seen in children and adolescents but also adults, usually following an acute stressor or
violent /often supernatural0 fright $ymptoms can occur days to years after an event $ymptoms7
by anxiety, agitation, lac2 of motivation or interest, sleep disturbance, changes in appetite, other
somatic symptoms, and a belief that the soul has been, or will be, stolen from the body
Taban<a /Trinidad0 "epression associated with a high rate of suicide that is seen in men
abandoned by their wives
Tai?in <yofusho /(apan0 ,ntense fear and guilt that oneIs appearance or behaviors displease,
embarrass or are offensive to others, prominent in younger people and similar to the Aestern
concept of social phobia
5fufuyane, /singular0, Amafufunyane, /plural0, sa<a BKenya, Southern AfricaI (antu, JuluI
and affiliated )rou9sC May e related to aluro BNi)eriaC, phii pob B4hailandC, and %ar B<)y9t,
<thio9ia, SudanC. &nxiety state attributed to the effects of magical potions /given to them by
re1ected lovers0 or spirit possession, with characteristic sobbing, repeated neologisms, paralysis,
trance+li2e states, or loss of consciousness $een in young, unmarried women, who may also
experience nightmares with sexual themes, and rarely episodes of temporary blindness
1'3
Far B<ast and North Africa, the Middle <ast e.). <thio9ia, Somalia, Sudan, <)y9t, and 2ranC,
Somalian $omen BSarC. "issociative symptoms including shouting, laughing, head banging,
singing, weeping, and other demonstrative behaviors The person believes they are possessed by
a spirit, and may develop a long+term relationship with the spirit )ther symptoms may include
apathy, withdrawal, refusal to eat, and refusal to carry out tas2s of daily living $uch behavior
may be regarded as culturally normal
eferences
&merican #sychiatric &ssociation /&#&07 "iagnostic and $tatistical *anual of *ental
"isorders, 4
th
?dition, Text <evision Aashington, "3, &#&, 2'''
@roup for the &dvancement of #sychiatry7 3ultural &ssessment in 3linical #sychiatry
Aashington, "3, &merican #sychiatry #ublishing, 2''2
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