What is the recommended treatment for a patient with conversion disorder, potentially with underlying psychological trauma and co-occurring depression or anxiety?

Treatment for Conversion Disorder

Primary Treatment Recommendation

Cognitive behavioral therapy (CBT) should be the primary treatment for conversion disorder, initiated as early as possible after diagnosis to maximize the likelihood of return to premorbid function. 1, 2, 3

Initial Diagnostic Communication

• A candid, clear but sympathetic discussion with the patient about the diagnosis is essential and represents the first therapeutic intervention. 1
• The discussion must acknowledge the involuntary nature of the symptoms while explaining that physical complaints have a psychological cause. 1, 4
• This conversation requires the physician to first be convinced of the diagnosis themselves before attempting to convince the patient. 4
• Combined consultation (neurology/medicine and psychiatry together) is a useful tool to help patients accept the diagnosis and engage in treatment. 4

Evidence-Based Psychotherapy Approaches

Cognitive Behavioral Therapy (Primary Recommendation)

• CBT is the psychotherapy modality with the strongest evidence base for conversion disorders. 1
• Uncontrolled studies suggest psychotherapy, particularly CBT, may be beneficial in conversion disorders, though one RCT showed only a non-statistically significant trend toward improvement at 3 months. 1
• CBT principles should be applied to address the underlying psychological distress manifesting as physical symptoms. 1

Alternative Psychotherapy Modalities

• Cognitive-analytical therapy has shown success in case studies of conversion disorder, particularly in pediatric patients. 5
• Psychodynamic psychotherapy may be considered for patients with adequate capacity to engage in the process, particularly when childhood trauma or alexithymia are present. 6
• The primary goal is helping patients recognize that their subjective suffering is symbolized through symptoms rather than consciously recognized. 6

Addressing Comorbid Psychiatric Conditions

Depression and Anxiety Treatment

• Mood and anxiety disorders are frequently comorbid with conversion disorder and must be treated, as their management may affect the prognosis of conversion symptoms. 2
• For comorbid depression or anxiety, SSRIs (sertraline, citalopram, escitalopram, fluoxetine, fluvoxamine, or paroxetine) should be considered as first-line pharmacotherapy. 7
• Combination therapy with CBT plus SSRI may be offered preferentially over monotherapy for patients with comorbid anxiety disorders. 7

Trauma-Related Considerations

• If underlying psychological trauma is present and meets criteria for PTSD, trauma-focused psychotherapy (Prolonged Exposure, Cognitive Processing Therapy, or EMDR) should be offered as first-line treatment. 8
• Trauma-focused therapies demonstrate 40-87% of patients no longer meeting PTSD criteria after 9-15 sessions. 8
• History of childhood trauma does not negatively affect treatment response and should not delay initiation of trauma-focused therapy. 8

Pharmacotherapy Considerations

Limited Role of Medications

• There are no data supporting significant benefit from pharmacotherapy for conversion disorder itself. 1
• Medications should be reserved for treating comorbid psychiatric conditions (depression, anxiety, PTSD) rather than the conversion symptoms directly. 1, 2

Medications to Avoid

• Benzodiazepines should be avoided or used only short-term for acute stabilization, given risks of abuse, dependence, and cognitive impairment. 7
• Antidepressant monotherapy is contraindicated if bipolar disorder has not been excluded, as it can trigger manic episodes. 9

Treatment Structure and Coordination

Early Intervention

• Early diagnosis and prompt initiation of treatment is critical to lessen financial burden and speed recovery. 3
• The neurologist or primary physician should complete a thorough evaluation and have a low threshold for psychiatric consultation. 2
• Prompt comanagement between neurology/medicine and psychiatry increases the likelihood of return to premorbid function. 2

Long-Term Management

• Coordination between specialists and general practitioners is essential, as treatment frequently requires long-term intervention. 4
• This approach requires patience and open-mindedness to motivate patients to recognize the value of psychotherapy. 4
• Physical therapy may be beneficial as an adjunctive treatment, particularly for motor conversion symptoms. 3

Common Pitfalls to Avoid

• Do not assume conversion disorder is malingering or factitious disorder—these are distinct conditions. 4
• Do not delay psychiatric referral while pursuing additional neurological testing once conversion disorder is suspected. 2
• Do not prescribe medications targeting the conversion symptoms themselves, as evidence does not support this approach. 1
• Do not dismiss the patient's suffering as "not real"—the symptoms are involuntary and cause genuine distress. 1, 4
• Avoid stigmatizing language or attitudes that may prevent the patient from engaging in psychological treatment. 4