Conversion disorder is defined by Diagnostic and Statistical Manual of Mental Disorders , 4th Edition, Text Revision, also known as the DSM-IV-TR, 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. Somatoform disorders are marked 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 DSM-IV-TR classifies conversion disorder as one of the somatoform disorders, first classified as a group of mental disorders by the DSM III in 1980. Other terms that are sometimes used for conversion disorder include pseudoneurologic syndrome, hysterical neurosis , and psychogenic disorder.
Conversion disorder is a major reason for visits to primary care practitioners. One study of health care utilization estimates that 25–72% of office visits to primary care doctors involve psychological distress that takes the form of somatic (physical) symptoms. Another study estimates that at least 10% of all medical treatments and diagnostic services are ordered for patients with no evidence of organic disease. Conversion disorder carries a high economic price tag. Patients who convert their emotional problems into physical symptoms spend nine times as much for health care as people who do not somatosize; and 82% of adults with conversion disorder stop working because of their symptoms. The annual bill for conversion disorder in the United States comes to $20 billion, not counting absenteeism from work and disability payments.
Conversion disorder has a complicated history that helps to explain the number of different names for it. Two eminent neurologists of the nineteenth century, Jean-Martin Charcot in Paris and Josef Breuer in Vienna were investigating what was then called hysteria, a disorder primarily affecting women (the term "hysteria" comes from the Greek word for uterus or womb). Women diagnosed with hysteria had frequent emotional outbursts and a variety of neurologic symptoms, including paralysis, fainting spells, convulsions, and temporary loss of sight or hearing. Pierre Janet (one of Charcot's students), and Breuer independently came to the same conclusion about the cause of hysteria—that it resulted from psychological trauma. Janet, in fact, coined the term "dissociation" 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 "combat neurosis" in World War I (1914-1918) and World War II (1939-1945). Many of the symptoms observed in "shell-shocked" soldiers were identical to those of "hysterical" women. Two of the techniques still used in the treatment of conversion disorder—hypnosis and narcotherapy—were introduced as therapies for combat veterans. The various terms used by successive editions of the DSM and the ICD (the European equivalent of DSM ) for conversion disorder reflect its association with hysteria and dissociation. The first edition of the DSM (1952) used the term "conversion reaction." DSM-II (1968) called the disorder "hysterical neurosis (conversion type)," DSM-III (1980), DSM-III-R (1987), and DSM-IV (1994) have all used the term "conversion disorder." ICD-10 refers to it as "dissociative (conversion) disorder."
DSM-IV-TR (2000) specifies six criteria for the diagnosis of conversion disorder. They are:
- 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 faked or produced intentionally.
- The symptom cannot be fully explained as the result of a general medical disorder, substance intake, 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 require 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.
DSM-IV lists four subtypes of conversion disorder: conversion disorder with motor symptom or deficit; with sensory symptom or deficit; with seizures or convulsions; and with mixed presentation.
Although conversion disorder is most commonly found in individuals, it sometimes occurs in groups. One such instance occurred in 1997 in a group of three young men and six adolescent women of the Embera, an indigenous tribe in Colombia. 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.
Another example of group conversion disorder occurred in Iran in 1992. Ten girls out of a classroom of 26 became unable to walk or move normally following tetanus inoculations. Although the local physicians were able to treat the girls successfully, public health programs to immunize people against tetanus suffered an immediate negative impact. One 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
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. One psychiatrist has defined the symptoms as "a code that conceals the message from the sender as well as from the receiver."
Two terms that are used in connection with the causes of conversion disorder are primary gain and secondary gain. Primary gain refers to the lessening of the anxiety and communication of the unconscious wish that the patient derives from the symptom(s). Secondary gain refers to the interference with daily tasks, removal from the uncomfortable situation, or increased attention from significant others that the patient obtains as a result of the symptom(s).
Physical, emotional, or sexual abuse can be a contributing cause of conversion disorder in both adults and children. In a study of 34 children who developed pseudoseizures, 32% had a history of depression or sexual abuse, and 44% had recently experienced a parental divorce, death, or violent quarrel. In the adult population, conversion disorder may be associated with mobbing, a term that originated among European psychiatrists and industrial psychologists to describe psychological abuse in the workplace. One American woman who quit her job because of mobbing was unable to walk for several months. Adult males sometimes develop conversion disorder during military basic training. Conversion disorder may also develop in adults as a long-delayed after-effect of childhood abuse. A 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.
In general, symptoms of conversion disorder are not under the patient's conscious control, and are frequently mysterious and frightening to the patient. The symptoms usually have an acute onset, but sometimes worsen gradually.
The most frequent forms of conversion disorder in Western countries include:
- Pseudoparalysis. In pseudoparalysis, the patient loses the use of half of his/her body or of a single limb. The weakness does not follow anatomical patterns and is often inconsistent upon repeat examination.
- Pseudosensory syndromes. Patients with these syndromes often complain of numbness or lack of sensation in various parts of their bodies. The loss of sensation typically follows the patient's notion of their anatomy, rather than known characteristics of the human nervous system.
- Pseudoseizures. These are the most difficult symptoms of conversion disorder to distinguish from their organic equivalents. Between 5% and 35% of patients with pseudoseizures also have epilepsy. Electroencephalograms (EEGs) or measurement of serum prolactin levels, are useful in distinguishing pseudoseizures from epileptic seizures.
- Pseudocoma. Pseudocoma is also difficult to diagnose. Because true coma may indicate a life-threatening condition, patients must be given standard treatments for coma until the diagnosis can be established.
- Psychogenic movement disorders . These can mimic myoclonus, parkinsonism, dystonia, dyskinesia, and tremor. Doctors 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.
- Pseudoblindness. Pseudoblindness is one of the most common forms of conversion disorder related to vision. Placing 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.
- Pseudodiplopia. Pseudodiplopia, or seeing double, can usually be diagnosed by examining the patient's eyes.
- Pseudoptosis. Ptosis, or drooping of the upper eyelid, is a common symptom of myasthenia gravis and a few other disorders. Some people can cause their eyelids to droop voluntarily with practice. The diagnosis can be made on the basis of the eyebrow; in true ptosis, the eyebrows are lifted, whereas in pseudoptosis they are lowered.
- Hysterical aphonia. Aphonia refers to loss of the ability to produce sounds. In hysterical aphonia, the patient's cough and whisper are normal, and examination of the throat reveals normal movement of the vocal cords.
Psychiatrists working in various parts of the Middle East and Asia report that the symptoms of conversion disorder as listed by DSM-IV and ICD-10 do not fit well with the symptoms of the disorder most frequently encountered in their patient populations.
The lifetime prevalence rates of conversion disorder in the general U.S. population are estimated to fall between 11 and 300 per 100,000 people. The differences in the estimates reflect differences in the method of diagnosis as well as some regional population differences. In terms of clinical populations, conversion disorder is diagnosed in 5%–14% of general hospital patients; 1%–3% of outpatient referrals to psychiatrists; and 5%–25% of psychiatric outpatients.
Among adults, women diagnosed with conversion disorder outnumber men by a 2:1 to 10:1 ratio; among children, however, the gender ratio is closer to 1:1. Less educated people and those of lower socioeconomic status are more likely to develop conversion disorder; race by itself does not appear to be a factor. There is, however, a major difference between the populations of developing and developed countries; in developing countries, the prevalence of conversion disorder may run as high as 31%.
Conversion 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. Newer techniques of diagnostic imaging have helped to lower the rate of medical errors.
Diagnosis of conversion disorder is complicated by its coexistence with physical illness in as many as 60% of patients. Alternatively 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 imaging studies that may be useful, and appropriate laboratory tests. The doctor will also take a thorough patient history that will include the presence of recent stressors in the patient's life, as well as a history of abuse. Children and adolescents are usually asked about their school experiences; one question they are asked is whether a recent change of school or an experience related to school may have intensified academic pressure.
In 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 "paralyzed" arm is dropped over the patient's face. In conversion disorder, the arm will not strike the face. Other tests include applying a mildly painful stimulus to a "weak" or "numb" part of the body. The patient's pulse rate will typically rise in cases of conversion disorder, and he or she will usually pull back the limb that is being touched.
Factors suggesting a diagnosis of conversion disorder
The doctor can also use a list of factors known to be associated with conversion disorder to assess the likelihood that a specific patient may have the disorder:
- Age. Conversion disorder is rarely seen in children younger than six years or adults over 35 years.
- Sex. The female to male ratio for the disorder ranges between 2:1 and 10:1. It is thought that higher rates of conversion disorder in women may reflect the greater vulnerability of females to abuse.
- Residence. People who live in rural areas are more likely to develop conversion disorder than those who live in cities.
- Level of education. Conversion disorder occurs less often among sophisticated or highly educated people.
- Family history. Children sometimes develop conversion disorder from observing their parents' reactions to stressors. This process is known as social modeling .
- A recent stressful change or event in the patient's life.
An additional feature suggesting conversion disorder is the presence of la belle indifférence . The French phrase refers to an attitude of relative unconcern on the patient's part about the symptoms or their implications. La belle indifférence is, however, much more common in adults with conversion disorder than in children or adolescents. Patients in these younger age groups are much more likely to react to their symptoms with fear or hopelessness.
Medical conditions that mimic conversion symptoms
It 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 diagnosis:
- multiple sclerosis (blindness resulting from optic neuritis)
- myasthenia gravis (muscle weakness)
- periodic paralysis (muscle weakness)
- myopathies (muscle weakness)
- polymyositis (muscle weakness)
- Guillain-Barré syndrome (motor and sensory symptoms)
Patients diagnosed with conversion disorder frequently benefit from a team approach to treatment and from a combination of treatment modalities. A 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.
While 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.
Psychodynamic psychotherapy is sometimes used with children and adolescents to help them gain insight into their symptoms. Cognitive behavioral approaches have also been tried, with good results. Family therapy is often recommended for younger patients whose symptoms may be related to family dysfunction. Group therapy appears to be particularly useful in helping adolescents to learn social skills and coping strategies, and to decrease their dependency on their families.
Hospitalization is sometimes recommended for children with conversion disorders who are not helped by outpatient treatment. Inpatient 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
Alternative and complementary therapies that have been shown to be helpful in the treatment of conversion disorder include hypnosis, relaxation techniques, visualization, and biofeedback .
The prognosis for recovery from conversion disorder is highly favorable. Patients 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. Of patients hospitalized for the disorder, over half recover within two weeks. Between 20% and 25% will relapse within a year. The individual symptoms of conversion disorder are usually self-limited and do not lead to lasting disabilities; however, patients with hysterical aphonia, paralysis, or visual disturbances, have better prognoses for full recovery than those with tremor or pseudoseizures.
The incidence of conversion disorder in adults is likely to continue to decline with rising levels of formal education and the spread of basic information about human psychology. Prevention of conversion disorder in children and adolescents depends on better strategies for preventing abuse.
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American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007.(202) 966-7300. Fax: (202) 966-2891. <www.aacap.org> .
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov> .
Rebecca J. Frey, Ph.D