Is Valium (diazepam) an effective treatment for a patient with conversion disorder, potentially with underlying psychological trauma and co-occurring depression or anxiety?

Valium (Diazepam) Should NOT Be Used for Conversion Disorder

Diazepam is not recommended for conversion disorder and may actually worsen outcomes—cognitive behavioral therapy (CBT) is the evidence-based first-line treatment. 1

Why Benzodiazepines Are Contraindicated

The evidence strongly argues against using benzodiazepines like diazepam for conversion disorder:

• Paradoxical intention therapy significantly outperformed diazepam in a head-to-head comparison, with 93.3% of patients responding to paradoxical therapy versus only 60% responding to diazepam at 6 weeks. 2

• Patients treated with paradoxical intention showed greater improvements in both anxiety scores (p<0.015) and conversion symptoms (p=0.034) compared to diazepam-treated patients. 2

• The WHO guidelines explicitly state that benzodiazepines should not be used for initial treatment of individuals with complaints in the absence of current/prior depressive episode/disorder, which applies to conversion disorder presentations. 1

Evidence-Based First-Line Treatment

CBT-based psychological interventions are the recommended treatment:

• CBT principles should be considered in adult help seekers with medically unexplained somatic complaints who are in substantial distress and do not meet criteria for depressive episode/disorder. 1

• The ACC/AHA/HRS guideline states that cognitive behavioral therapy may be beneficial in patients with pseudosyncope (a form of conversion disorder), though evidence shows a non-statistically significant trend toward improvement at 3 months. 1

• There are no data that support significant benefit from pharmacotherapy for conversion disorder/pseudosyncope. 1

When Antidepressants May Be Considered

If there is co-occurring depression or anxiety (present in 95% of conversion disorder patients), antidepressants may have a role: 3

• SSRIs (citalopram or paroxetine) or venlafaxine showed marked improvement in patients with psychogenic movement disorder (a conversion subtype) when primary conversion disorder coexisted with current or previous depressive/anxiety disorder. 4

• 67% of patients with primary conversion disorder had complete remissions when treated with antidepressants, but this was specifically in those with comorbid depression/anxiety. 4

• However, patients with primary hypochondriasis or somatization disorder (33% of the sample) showed no improvement with antidepressants. 4

Practical Management Approach

The psychological management strategy should include: 5

• Avoiding confrontation with the patient about the psychological nature of symptoms
• Reviewing test results and creating an expectation of recovery
• Providing a benign explanatory model of symptoms
• Evaluating emotional adjustment and referring for psychotherapy
• Using behavior therapy reinforcement for chronic or resistant symptoms

A candid discussion with the patient about the diagnosis may be reasonable, delivered in a clear but sympathetic manner that acknowledges the involuntary nature of the attacks. 1

Critical Pitfall to Avoid

Never use benzodiazepines as primary treatment for conversion disorder—the evidence demonstrates inferior outcomes compared to psychological interventions, and they do not address the underlying mechanism of the disorder. 2 If anxiety or depression are prominent and impairing, consider SSRIs rather than benzodiazepines. 4