Conversion Disorder

Conversion disorder, also known as functional neurologic symptom disorder, is a psychiatric condition where patients present with neurological symptoms, such as numbness, blindness, paralysis, or seizures, that lack a consistent organic cause but can be linked to psychological factors. This disorder often arises in response to significant stress or trauma.

Signs and Symptoms

Conversion disorder usually manifests suddenly, often triggered by psychological distress. Symptoms typically affect sensory or motor functions and are not aligned with known anatomical pathways. Common symptoms include:

• Motor Symptoms: Impaired coordination, weakness or paralysis, speech impairment, swallowing difficulties, urinary retention, psychogenic seizures, persistent dystonia, tremors, gait problems, and loss of consciousness.
• Sensory Symptoms: Impaired vision (including blindness), impaired hearing (deafness), and disturbances in touch or pain sensation.

These symptoms generally reflect the patient’s understanding of anatomy and often do not conform to known physiological mechanisms.

Diagnosis

Definition

Conversion disorder is encapsulated under the broader term functional neurological symptom disorder. The DSM-5 criteria for diagnosis include:

1. At least one symptom of altered voluntary motor or sensory function.
2. Clinical evidence of incompatibility between the symptom and recognised neurological or medical conditions.
3. The symptom is not better explained by another medical or mental disorder.
4. The symptom causes significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Exclusion of Neurological Disease

A very important step in diagnosing conversion disorder is the exclusion of neurological diseases such as stroke, multiple sclerosis, or epilepsy. Neurologists must rely on careful examination and appropriate investigations. Historically, certain signs like la belle indifférence and symptom severity on the non-dominant side were used, but these have been questioned for their validity.

Deliberate Feigning

Conversion disorder is susceptible to deliberate feigning. Neuroimaging studies suggest that feigning can be distinguished by specific patterns of frontal lobe activation.

Psychological Mechanism

The psychological mechanisms leading to conversion symptoms are not fully understood. Although psychological stressors can be identified in some cases, many patients with medically unexplained neurological symptoms may not have a clear psychological trigger.

Treatment

Treatment for conversion disorder can include multiple approaches:

1. Occupational Therapy: Helps maintain daily living activities.
2. Physiotherapy: Aids in managing physical symptoms.
3. Psychological Counselling: Educates patients on the causes of their symptoms and helps manage both psychiatric and physical aspects of the condition.
4. Other Treatments: Cognitive behavioural therapy, hypnosis, EMDR, psychoanalytic treatment, and EEG brain biofeedback. However, these treatments require further trials as current evidence is limited.

Prognosis

The prognosis for conversion disorder varies widely. Some cases resolve within weeks, while others persist for years. Although some patients may achieve remission, relapse is possible.

Epidemiology

Frequency

The prevalence of conversion disorder is uncertain due to diagnostic complexities. In neurology clinics, unexplained symptoms are prevalent, but the proportion attributable to conversion disorder is unclear. General population estimates suggest a prevalence between 0.011% and 0.5%.

Culture

Conversion disorder may be more frequent in rural, lower socio-economic groups with limited access to medical investigation.

Gender

Conversion disorder historically affected more women, partially due to higher rates of violence against women. Modern surveys show a higher prevalence in females, with a ratio ranging from 2:1 to 6:1 compared to males.

Age

The condition is rare in children under ten and the elderly, with a peak onset in the mid-to-late 30s.

History

The history of conversion disorder dates back to ancient times when it was often attributed to the uterus and termed "hysteria." Over centuries, the understanding of the disorder evolved from a uterine cause to a neurological and then a psychological origin. Freud and Janet provided significant insights, contributing to the modern understanding of conversion disorder as a condition linked to psychological and emotional factors.

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Self-assessment MCQs (single best answer)

Which of the following is NOT a common symptom of conversion disorder?

What is a necessary criterion for diagnosing conversion disorder according to the DSM-5?

Which professional is typically involved in the exclusion of neurological diseases when diagnosing conversion disorder?

Which of the following treatments is NOT commonly used for managing conversion disorder?

Which age group is least likely to be affected by conversion disorder?

What historical term was used to describe conversion disorder?

What is the gender ratio prevalence of conversion disorder in modern surveys?

Which of the following is a sensory symptom of conversion disorder?

Conversion disorder is also known as:

A common psychological treatment method for conversion disorder that requires further trials for efficacy is: