Conversion Disorder

What is conversion disorder?

A conversion disorder is a nerve-related condition that is due to psychological stress or trauma. While not fully understood, the symptoms develop in response to stress or trauma that lead to intolerable conflict. The psychological cause may occur in one instance or on a repetitive basis prior to onset of symptoms. Onset of this type of nerve-related symptom can occur immediately after the stressor or trauma, or it can occur after a delay of many years.

The symptoms are neurological in nature:

  • Weakness or paralysis
  • Parathesias (i.e., numbness and/or tingling)
  • Pain
  • Blindness
  • Loss of speech abilities
  • Loss of hearing
  • Non-epileptic or psychogenic seizures
  • Fainting spells

These symptoms can occur singularly or in combination.

Despite having a relationship to stress, conversion disorders differ from most stress-related health problems. Many stress-related health problems are common and will occur to most everyone at some point in their lives. Most everyone, for instance, has had a tension headache or an upset stomach. As their descriptions suggest, these conditions are manifestations of emotional stress. Conversion disorders are different and much less common.

An important characteristic differentiates conversion disorders from other stress-related health problems. Conversion disorder symptoms tend to reflect an intolerable conflict in a way that is unique to the particular stressor or trauma. For example, suppose a man witnesses the violent deaths of innocent children in war; because of the intolerable nature of this trauma, he develops blindness; after all possible medical explanations are exhausted, the blindness is diagnosed as a conversion disorder. Another example might be a woman who was unsuccessful in her attempts to save her children in a house fire and ended up having to run out to save her own life; the intolerable conflict inherent in this trauma leads to paralysis of her legs; after no viable medical explanation is found, the paralysis is diagnosed as a conversion disorder. Notice how the symptoms tend to manifest the conflict that each individual experienced and seems essentially unique to the conflict itself. The unique way that conversion disorders manifest the stressful problem is different from most common stress-related health problems. There is nothing unique about a tension headache or an upset stomach. Countless stressful problems can lead to them. In conversion disorders, however, the symptoms tend to be unique to the stressful problem that the patient experienced.

Sometimes, with conversion disorders, there isn't such a direct one-to-one relationship between the intolerable conflict and the nerve-related symptom, such as witnessing trauma and becoming blind or running out of burning house and becoming paralyzed. Nonetheless, the symptom continues to have a unique relationship to the intolerable conflict in that it prevents the patient from having to come to terms with the intolerable conflict. Non-epileptic, or psychogenic seizures, can occur in this manner. An example might be a young professional who develops non-epileptic seizures at about the same time as it has become clear that he has been promoted to early and is insufficiently prepared for his position and so is on the verge of being let go; the non-epileptic seizures inhibit him from having to deal with the intolerable conflict within his career. As such, conversion disorders don't always have a direct, one-to-one relationship to the intolerable conflict, but they nonetheless inhibit the patient from having to face the intolerable conflict and come to terms with it.

It is important to recognize that patients with a conversion disorder do not intentionally make up their symptoms. They do not decide to have the symptoms and cannot simply decide to stop having the symptoms.

Diagnosis of a conversion disorder is based on a) the presence of symptoms which are neurological in nature, b) the symptoms have some relationship to a stressor or trauma that led to intolerable conflict, c) all other viable medical explanations have been exhausted or ruled-out, and d) the person with the symptoms are not making them up.1 

Healthcare providers are often reluctant to diagnose a conversion disorder.2 Many factors lead to such reluctance:

  • Concern about stigmatizing the patient
  • Concern that the patient will have difficulty accepting the diagnosis and will subsequently become angry with the healthcare provider
  • Concern about legal action and/or licensing board complaints if a patient is angry with the diagnosis; even if unfounded, responding to such actions require time and money
  • Concern about the possibility of having the diagnosis proven wrong by medical testing down the road

Because of their reluctance, healthcare providers tend to refrain from diagnosing a conversion disorder and instead proceed with either a) lots of further testing which assess for medical explanations that are unlikely to occur, b) create cycles of false-hope and disappointment for the patient when further and further testing continue to come back with negative results, and c) are expensive to the patient and the healthcare system.

It is important to recognize that stress and trauma are just as legitimate a way of becoming ill as any other possible cause of health problems.

Is there a cure for conversion disorder?

The course of a conversion disorder can vary across different individuals. A conversion disorder can sometimes resolve either on its own or in treatment. It can also become chronic. In simple tracking studies, roughly 50% of patients had recovered at four and ten year follow-ups.3, 4 

Therapies & procedures for conversion disorders

Clinical knowledge of conversion disorders suffers from a notable lack of well-designed research studies.5 As such, treatment is typically guided by conventional wisdom within the healthcare community and clinical judgment of the particular healthcare provider.

Conventional wisdom in the healthcare community is that conversion disorders are best treated psychologically, through psychodynamic psychotherapy. This type of psychotherapy provides a safe and empathic relationship with a trusted provider who can assist the patient in working through the following issues:

  • Acceptance of the diagnosis
  • Understanding of how such symptoms can occur
  • Coming to a meaningful resolution of the intolerable conflict

Without shame or guilt, the patient comes to find meaning in the stressful event that brought about the symptoms and consequently the patient comes to be able to ‘move on’ with the rest of his or her life. It is often a difficult process. Initially, motivational interviewing interventions may be necessary to assist the patient in coming to accept the diagnosis.

There is limited evidence that antidepressant medications might be mildly helpful.6, 7

Conventional wisdom suggests that physical therapy and occupational therapy can be helpful in managing the symptoms.

References

1. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author.

2. Gratten-Smith, P., Fairly, M., & Procopic, P. (1988). Clinical features of conversion disorder. Archives of Disease in Childhood, 63, 408-414.

3. Couprie, W, Wijdicks, E. F., Rooijmans, H. G., & van Gijn, J. (1995). Outcome in conversion disorder: A follow up. Journal of Neurology, Neurosurgery, and Psychiatry, 58, 750-752.

4. Mace, C. J., & Trimble, M. R. (1996). Ten-year prognosis of conversion disorder. British Journal of Psychiatry, 196, 282-288.

5. Ruddy R., & House, A. (Updated August 22, 2005). Psychosocial interventions for conversion disorder. In Cochrane Database of Systematic Reviews, 2005 (4). Retrieved May 3, 2012, from The Cochrane Library, Wiley Interscience.

6. Fishbain, D. A., Cutler, R. B., Rosomoff, H. L., & Rosomoff, R. S. (1998). Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosomatic Medicine, 60, 503-509.

7. Voon, V. & Lang, A. E. (2005). Antidepressant treatment outcomes of psychogenic movement disorder. Journal of Clinical Psychiatry, 66, 1529-1534.

 

Date of publication: April 27, 2012

Date of last modification: September 8, 2016

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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