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Conversion Disorders

(слайд 1) Conversion disorder, as stated in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV), involves symptoms or deficits affecting voluntary motor or
sensory function that suggest a neurological or other general medical condition. Yet, following a
thorough evaluation, which includes a detailed neurological examination and appropriate
laboratory and radiographic diagnostic tests, no neurological explanation exists for the symptoms.

Examples of conversion symptoms include blindness, diplopia, paralysis, seizures,

anesthesia, aphonia, amnesia, unresponsiveness, and difficulty walking. Conversion disorder
represents one type of somatoform disorder. The essential element of all somatoform disorders is
the presence of physical symptoms or signs that cannot be explained by a medical condition.
Unlike factitious disorders and malingering, the symptoms of somatoform disorders are not
intentional or under voluntary control.

The idea that conversion disorder does not have an organic basis has become entrenched.
However, some evidence supports the opposite notion. Studies on the natural history of
conversion disorder indicate that many patients subsequently develop neurological disease. The
simultaneous occurrence of organic brain disease with conversion symptoms also is observed.
Familial studies have shown that conversion symptoms in first-degree female relatives are up to
14 times greater than in the general population.

• (слайд 2) In the US: Stefansson et al report that the annual incidence of conversion
reactions is 22 cases per 100,000 persons per year in New York. However, the reported rates
vary widely. In a study of 100 consecutive women following a normal full-term pregnancy, 33 were
noted to have a past history of conversion symptoms. In a study of 100 randomly selected patients
from a psychiatry clinic, 24 were noted to have unexplained neurological symptoms. It is reported
to be more common in rural populations, in individuals with lower socioeconomic status, and in
individuals with less medical knowledge.

• Internationally: Stefansson et al report that the annual incidence is 11 cases per 100,000
persons per year in Iceland.

Sex: The female-to-male ratio is 2-10:1.

Age: The typical onset is between the second and fourth decades. The reported range is from
children to individuals in their ninth decade of life.
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History: Conversion symptoms are those that suggest neurological disease, but no
explanation of these symptoms is found following physical examination and diagnostic testing.
Conversion symptoms are seen in various clinical settings and include conversion disorder;
somatization disorder; affective disorders; antisocial personality disorder; alcohol or drug abuse;
or organic, neurological, or medical illnesses. In some situations, an immediate precipitating
source of stress may be disclosed, such as a loss of employment or divorce. The patient may
have a discordant home life. A history of sexual or physical abuse is not uncommon. Therefore, a
complete and comprehensive psychosocial history is important. It has been stated that patients
with conversion disorder have a relative lack of concern about the nature or implications of the
symptoms (la belle indifference). This is not a helpful diagnostic characteristic because it is not
specific or sensitive for conversion.

• (слайд 3, 2 шт.) Diagnostic criteria for conversion disorder as per the DSM-IV are as follows:

o One or more symptoms or deficits are present that are affecting voluntary motor or sensory
function and suggest a neurological or other general medical condition.

o Psychological factors are judged to be associated with the symptoms or deficits because the
initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

o The symptom or deficit is not produced intentionally or feigned, as in factitious disorder or

malingering.

o The symptoms or deficit cannot, after appropriate investigation, be explained fully by a

general medical condition, by the direct effects of a substance, or as a culturally sanctioned
behavior or experience.

o The symptom or deficit causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or warrants medical evaluation.

o The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively
during the course of somatization disorder, and is not better accounted for by another mental
disorder.

Possibilities to consider when a patient presents with symptoms of probable psychogenic origin
include the following:

o Symptoms are exclusively a function of somatoform disorder, factitious disorder, or

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malingering.

o Symptoms are secondary to other psychiatric etiologies such as panic disorder or

depression.

o Symptoms coexist with a physical disorder.

o The symptoms are an unusual manifestation of a physical disorder.

The DSM-IV lists strict criteria for diagnosing conversion disorder. However, 2 of the listed
conditions may be determined only by a person with expertise in neurological conditions,
neuroanatomy, and the recognized clinical patterns of disease in correlation with the lesion
location. The neurologist must recognize the nonorganic process and rule out imitators while
avoiding potentially dangerous diagnostic or therapeutic interventions. Patients with conversion
disorder may present with hemiparesis, paraparesis, monoparesis, alteration of consciousness,
visual loss, seizurelike activity, pseudocoma, abnormal gait disturbance, aphonia, lack of
coordination, or a bizarre movement disorder. The presenting symptoms depend on the cultural
milieu, the degree of medical sophistication, and the underlying psychiatric issue.

Observations when the patient is unaware of being examined are helpful. Patients with
psychogenic movements may have no such movements when observed in the waiting room.
Multiple examinations by one or more practitioners may disclose variable results. However,
caution is necessary when applying these rules. No single feature is absolute. The knowledge
pertaining to neuroanatomy and the clinical deficits that arise from abnormalities is not completely
known, thus resulting in limitations of the neurological examination. In addition, patients can
embellish on organic deficits. Therefore, only a presumptive diagnosis can be made after the initial
evaluation.

Further complicating the assessment is the knowledge that up to 30% of patients with
conversion disorder develop a physical illness that may account for their symptoms if followed
longitudinally. It also is not uncommon for patients with conversion disorder to have a comorbid
medical or neurological illness. An example is the patient with both epileptic seizures and
pseudoseizures.

Other specific details to help diagnose 3 different conversion symptoms include the
following:

• (слайд 4) Psychogenic hemiparesis. Unilateral weakness or hemiparesis is one manner

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in which the patient with conversion disorder may present. Classic hemiparesis represents a
deficit of the corticospinal tract. In an acute lesion of the corticospinal tract, a patient may
demonstrate flaccidity of the weak limbs, which is associated with decreased reflexes. In more
chronic lesions, the patient may develop spasticity of the affected limbs, hyperreflexia, and an
extensor toe sign (positive Babinski). The patient with hemiparesis from a corticospinal tract lesion
may demonstrate weakness of the extensor muscles to a greater extent than the flexor muscles
and may show greater weakness distally than proximally. None of these findings would likely be
seen in the patient with conversion disorder. In psychogenic hemiparesis, the muscle contractions
are poorly sustained and may give way abruptly as the patient resists the force exerted by the
examiner.

The Hoover sign also may be elicited. When a patient in the recumbent position flexes the thigh
and lifts the leg, the downward movement of the contralateral leg is automatic. The examiner
places a hand beneath the heel and asks the patient to raise the paretic leg. In feigned weakness,
no appreciable downward movement is evident. In addition, when the patient is asked to raise the
normal leg, the downward movement is appreciated from the "paretic" leg.

Recognizing the patient with psychogenic hemiparesis includes observing the following:

 No changes in reflexes
 No changes in tone
 Give-way quality of weakness
 Extensor and flexor muscles equally weak
 Contralateral sternocleidomastoid weakness
 Positive Hoover sign
 Difference between formal examination and general observations

• (слайд 5) Pseudoseizure. Distinguishing between a pseudoseizure (which can be

defined as a nonepileptic or psychogenic seizure) and an epileptic seizure is challenging. The
manifestations of each are diverse, and the clinical diagnosis rests on historical information from
witnesses with varying observational skills. Simultaneous video electroencephalogram (EEG)
monitoring has significantly improved the accuracy of diagnosis, but this technique is expensive
and not routinely available. Psychogenic seizures may constitute up to 20% of all patients in an
epilepsy referral center. Classic clues that suggest nonepileptic seizure include the following:

 Ineffectiveness of multiple antiepileptic drugs

 Induced by stress
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 Lack of physical injury
 Lack of headache or myalgias following convulsions
 Lack of incontinence
 Biting the tip of the tongue as opposed to the side or the lip
 History of sexual or physical abuse
 Signs or symptoms suggestive of another conversion

Ictal characteristics that suggest nonepileptic seizure include the following:

 Gradual onset of ictus

 Prolonged duration (>4 min)
 Atypical or excessive motor activity such as thrashing, rolling from one side to
the other, pelvic thrusting, or arrhythmic (out-of-phase) jerking
 Waxing and waning amplitude
 Intelligible speech
 Bilateral motor activity with preserved consciousness
 Clinical features that change from one spell to the next (ie, nonstereotyped)
 Lack of postictal confusion
 Postictal crying or cursing
 Directed violent acts
 Resistance to eye opening
 Purposeful resistance to passive movements

• (слайд 6) Psychogenic movement disorders. Conversion disorder can imitate the entire
spectrum of movement disorders and include tremor, chorea, myoclonus, dystonia, tics,
parkinsonism, and a host of bizarre gait disturbances (astasia-abasia).

Clinical symptoms or signs that may help distinguish psychogenic movements from organic ones
include the following:

 Abrupt onset of symptoms

 Character of movements atypical of recognized patterns and have inconsistent amplitude,
frequency, and distribution
 Characteristics of movements change over time
 Entrainment of the tremor to the rate requested by the examiner
 Spontaneous remissions
 Movements disappear with distractions
 Movements increase with attention
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 Response to placebo, psychotherapy, or suggestion
 Paroxysmal symptoms
 Nonobjective weakness or sensory changes also present

• Tactful presentation of the diagnosis to the patient includes the following:

o Do not tell patients that nothing is wrong with them.

o Do not inform the patient of the diagnosis on the first encounter.

o Reassure the patient that the symptoms are very real despite the lack of a definitive
organic diagnosis.
o Provide socially acceptable examples of diseases that often are deemed stress-
related (eg, peptic ulcer disease, hypertension).
o Provide common examples of emotions producing symptoms (eg, queasy stomach
when talking in front of an audience, sweaty palms when asking someone for a date).
o Provide examples of how the subconscious influences behavior (eg, nail biting,
pacing).
o Provide reassurance that no evidence of an underlying neurological disorder is
present based on the tests that were performed and that the prognosis for recovery is very good.
o Provide positive reinforcement that the symptoms can improve spontaneously.
o Inform patients that the symptoms are not volitional, and no one believes that they
are faking.

(слайд 7) Psychiatric treatments that have demonstrated effectiveness include the following:

o Psychodynamic therapy: Patients with borderline intelligence, lack of motivation or

introspection capabilities, important secondary gains, or those with a tendency for behavioral
acting out likely are poor candidates.
o Behavioral therapy: The inappropriate behavior no longer is rewarded or may even
be punished. An advantage is that neither normal intelligence nor insight is necessary for success.
A disadvantage is that behavioral therapy relies on controlling the environmental conditions, which
may not be feasible.

• Family therapist: Interactions and communication within the family are emphasized rather
than only focusing on the individual patient.

(слайд 8) Prognosis:
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• Spontaneous resolution in most - Approximately 75%

• Recurrence of same or different conversion symptoms - Approximately 25% in 15-year

follow-up studies

• Good prognostic factors - Acute onset of symptoms, short duration of symptoms, healthy
premorbid functioning, higher intelligence, absence of coexisting psychopathology, presence of an
identifiable stressor

• Poor prognostic symptoms - Pseudoseizure, psychogenic tremor