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

Pharmacologic Management of Conversion Disorder

Primary Recommendation

Pharmacotherapy is not recommended as first-line treatment for conversion disorder itself; instead, psychotherapy—particularly cognitive behavioral therapy—should be the primary intervention, with medications reserved exclusively for treating co-occurring psychiatric conditions like depression or anxiety. 1, 2, 3

Treatment Algorithm

Step 1: Assess for Co-Occurring Psychiatric Disorders

• Screen specifically for depression and anxiety, as 95% of patients with conversion disorder have co-morbid anxiety and/or depressive symptoms 4
• Depression is present in 29% of cases, anxiety in 35%, and both conditions in 31% of patients with conversion disorder 4
• Use validated screening tools to quantify severity of these co-occurring conditions 4

Step 2: Initiate Psychotherapy as Primary Treatment

• Cognitive behavioral therapy should be the cornerstone of treatment for conversion disorder, with no data supporting significant benefit from pharmacotherapy for the conversion symptoms themselves 1, 2
• Behavioral activation techniques within CBT specifically target symptom patterns and re-engage patients with functional activities 5
• Psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process 2

Step 3: Consider Pharmacotherapy ONLY for Co-Occurring Conditions

For Co-Occurring Depression:

• If anhedonia is NOT the predominant symptom: Consider second-generation antidepressants, particularly sertraline, which has been studied extensively and has lower risk of QTc prolongation 1
• If anhedonia IS predominant: Avoid SSRIs/SNRIs as first-line agents, as they show limited efficacy and may worsen anhedonic symptoms 5
• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse 5

For Co-Occurring Anxiety:

• SSRIs (particularly sertraline) are appropriate for anxiety management in this population 1
• Avoid benzodiazepines, as they are not indicated for depressive symptoms and carry risks of dependence 5

Step 4: Medication Selection Considerations

Preferred Agents:

• Sertraline: Most extensively studied SSRI with favorable cardiovascular safety profile 1
• Mirtazapine: Safe alternative with additional benefits including appetite stimulation and sleep improvement 1

Agents to Avoid:

• Monoamine oxidase inhibitors and tricyclic antidepressants due to significant cardiovascular side effects 1
• Citalopram or escitalopram due to higher risk of QTc prolongation compared to sertraline 1

Critical Pitfalls to Avoid

• Do not prescribe medications to treat conversion symptoms directly—there is no evidence supporting pharmacotherapy for the conversion disorder itself 1, 2
• Do not use benzodiazepines for managing conversion disorder or co-occurring depression 5
• Do not discontinue antidepressants prematurely if prescribed for co-occurring depression; maintain treatment for minimum 9-12 months after recovery 5
• Do not confront patients about the psychological nature of their symptoms in a manner that suggests malingering, as conversion disorder is not malingering or factitious disorder 3, 6

Special Considerations

Delivering the Diagnosis

• Provide a benign explanatory model that acknowledges the involuntary nature of symptoms while creating an expectation of recovery 1, 3
• Combined consultation (medicine and psychiatry) is a useful tool to help patients accept the diagnosis and engage in psychotherapy 6
• Physicians must first convince themselves of the diagnosis before trying to convince patients 6

Underlying Trauma

• Evaluate for history of childhood trauma, which is a well-established predisposing factor for conversion disorder 2
• Address psychological trauma through psychotherapy rather than pharmacological interventions 1

Treatment Duration

• Psychotherapy frequently requires long-term intervention with coordination between specialists and general practitioners 6
• For co-occurring depression, maintain treatment for 4-9 months after satisfactory response for first episodes, and ≥1 year for recurrent episodes 5