What is conversion disorder?

Conversion Disorder: Understanding and Management

Conversion disorder is a somatic symptom disorder characterized by neurological symptoms that cannot be explained by an underlying neurologic disorder, and is now classified as "functional neurological symptom disorder" in the DSM-5. 1, 2

Clinical Features and Presentation

• Conversion disorder presents with a wide range of neurological symptoms including motor, sensory, or autonomic dysfunction that cannot be explained by medical conditions 1
• Symptoms typically worsen with attention and improve with distraction, often developing in the context of injury, illness, or psychological distress 3, 2
• Common presentations include neurologic symptoms such as weakness, numbness, abnormal movements, speech difficulties, seizure-like episodes, or sensory disturbances 1, 3
• Symptoms result in significant impairment in psychosocial functioning (relationships with family/friends, academic or occupational difficulties) 1
• Conversion disorder should not be confused with malingering (which implies direct financial or emotional gain due to feigning illness) 1

Diagnostic Criteria

• Somatic symptoms that are distressing or significantly disrupt daily life 1
• Excessive thoughts, feelings, or behaviors related to the somatic symptoms, manifested by at least one of:
  • Disproportionate and persistent thoughts about symptom seriousness
  • Persistently high anxiety about health or symptoms
  • Excessive time and energy devoted to symptoms or health concerns 1
• Symptoms may not be continuously present, but the symptomatic state is persistent (typically >6 months) 1
• Symptoms must be involuntary - this distinguishes conversion disorder from factitious disorders or malingering 1

Differential Diagnosis

• Neurological disorders must be ruled out through comprehensive evaluation 1
• Key differential diagnoses include:
  • Guillain-Barré syndrome and its variants 1
  • Multiple sclerosis and other demyelinating disorders 1
  • Myasthenia gravis 1
  • Stroke or other vascular events 1
  • Metabolic disorders (electrolyte abnormalities, vitamin deficiencies) 1
  • Inflammatory or infectious conditions affecting the nervous system 1
  • Functional disorders (distinct from conversion) 1

Clinical Assessment

• Diagnosis requires positive clinical findings of internal inconsistency or incongruity with recognized neurological disease 4
• Symptoms often show variable frequency, amplitude, and direction that can be influenced by voluntary movements 3
• Characteristic features include:
  • Entrainability (symptoms can be influenced by external stimuli)
  • Distractibility (symptoms improve when attention is diverted)
  • Suggestibility (symptoms can be modified by suggestion) 3
• Neuropsychological testing may reveal differences in cognitive functioning compared to healthy controls, particularly in learning, memory, executive functions, and attention 5

Treatment Approach

• Psychotherapy, not medication, is the first-line treatment for conversion disorder, as there is no evidence supporting significant benefit from pharmacotherapy specifically for functional symptoms 2
• Cognitive Behavioral Therapy (CBT) has shown benefit for patients with functional neurological symptoms 3, 2, 6
• Clear, empathetic explanation of the diagnosis that acknowledges the involuntary nature of symptoms is crucial for treatment success 3, 2
• For specific symptoms like functional tremor, specialized techniques include:
  • Rhythm modification (superimposing alternative voluntary rhythms)
  • Entrainment techniques (using unaffected limbs to dictate new rhythms)
  • Music incorporation to override tremor patterns 3
• Pharmacotherapy should be limited to treating comorbid conditions rather than targeting conversion symptoms directly 2
• Minimizing the use of adaptive equipment is recommended, as aids are generally unhelpful in the rehabilitation process 3, 2

Prognosis

• The typical course of conversion disorder is relatively short, usually lasting about two weeks 7
• Only 20-25% of patients relapse in the following year 7
• However, some cases can become chronic, with symptoms persisting for years 7, 8
• Early diagnosis and interdisciplinary treatment approach are important for better outcomes 8

Treatment Pitfalls to Avoid

• Reinforcing illness behavior through excessive focus on symptoms or providing unnecessary aids 3, 2
• Taking a dismissive approach that fails to acknowledge the involuntary nature of symptoms 3, 2
• Overreliance on pharmacotherapy, which has limited evidence for treating conversion symptoms directly 3, 2
• Failure to address underlying psychological factors when present 6