Conversion disorder is a condition that presents as an impairment or loss of a physical function suggestive of a physical disorder but is actually the expression of an underlying psychological conflict or need. The symptom(s) are not under voluntary control. Unexplainable physical symptoms seen in conversion disorder may include a disturbance of sensation, muscle strength, seizures, involuntary movement, or some combination of these. Psychodynamic theory proposes that these symptoms develop in the presence of unconscious psychological conflict and stress, which in turn is expressed ("converted") in the form of a physical ailment. The physical symptom is thought to reduce anxiety by preventing conscious recognition of the frightening underlying psychological conflict. This is the primary gain from the symptoms.
The individual may also benefit from the symptoms in other ways (secondary gain) such as gaining attention or support from family and friends, a reward of some kind, or avoidance of unwanted responsibilities. Although most individuals appear unconcerned emotionally about their illness and are unaware of any psychological conflicts, some experience anguish over their new symptoms. The symptoms are not intentionally or consciously faked but there is no known medical condition to account for the findings. Instead of corresponding to any known anatomic or neurological patterns typical of illness having a physical basis, the symptoms may instead correspond to the individual's concept of a disease.
Conversion disorder is diagnosed only after a thorough medical examination fails to find a physical explanation for the symptoms. Some diseases take years for diagnosis so conversion disorder should be considered a tentative, working diagnosis. Even when a known disease is present, conversion disorder can still exist if the symptoms cannot be explained by the medical illness. Up to two-thirds of those with conversion disorder also have a neurological condition.
The symptoms of a conversion disorder are not drug-related or part of a culturally approved ritual or behavior. Conversion disorder is not diagnosed if symptoms are limited to pain or sexual dysfunction. These have separate diagnoses.Risk: Predisposing causes include prior physical disorders, exposure to people with real physical symptoms, and severe psychosocial stressors. Onset is usually between ages 10 and 35. It is more frequent in women (anywhere from 2 to 10 times more prevalent than in men), and in rural settings, lower socioeconomic groups, and military personnel exposed to combat. Studies indicate that conversion disorder may be found in between 1% to 14% of general medical and surgical inpatients (DSM-IV-TR). Incidence and Prevalence: The prevalence of conversion disorder varies widely ranging from 1 to 30 per 10,000 individuals. |
Source: Medical Disability Advisor
History: Individual has history of a sensory disturbance (i.e., numbness, double vision, blindness, deafness, or hallucinations), muscle disturbance (localized weakness or paralysis, incoordination, difficulty swallowing, or a "lump in the throat"), convulsions (seizures), or some combination of these. The disturbance closely follows a major psychological stress or conflict but the symptoms are not faked or intentionally produced. Symptoms cannot be fully explained by a general medical condition, the direct effects of a drug or other substance such as alcohol, or as a culturally typical behavior or experience. Significant distress, alteration in interpersonal relationships, or decrease in occupational functioning must be present. The symptoms are not limited to pain or sexual dysfunction and are not better explained by another mental disorder. Physical exam: The exam shows findings inconsistent with medical knowledge. Numbness is often in a pattern resembling a glove or stocking, not the pattern of the known nerve supply. A paralyzed body part may not perform according to known nerve and muscle anatomy. Muscle strength may be normal in muscles opposite the "paralyzed" ones and reflexes are normal. Various specialized examination maneuvers can help the doctor differentiate complaints related to physical causes from those that are conversion symptoms; e.g., in hysterical blindness, nystagmus is observed when the individual is confronted with a moving painted cylinder (optokinetic nystagmus), confirming that from a physiologic standpoint, the visual pathways are intact. Tests: Neurological tests are normal. Electromyogram (EMG) and nerve conduction velocity testing are normal in "paralyzed" muscles. Somatosensory evoked potential testing is normal in limbs with no sensation. Electroencephalogram (EEG) is normal in conversion seizures. Psychological tests such as the Minnesota Multiphasic Personality Inventory - 2 (MMPI-2) may show a profile characteristic of conversion disorder. |
Source: Medical Disability Advisor
| Psychotherapy, based on a psychodynamic theory, is thought to be helpful by resolving the intrapsychic conflict manifested in the conversion symptom. As an alternative, non-challenging application of cognitive-behavioral therapy may be more effective - the goals being to unlearn maladaptive responses and to learn more appropriate responses to stressors. Because individuals may be resistant to the idea that symptoms are the result of a psychological problem, therapy of any type is usually couched in terms of stress reduction and coping skills for a chronic illness. Therapy should avoid reinforcing the sick role as a solution to the problem. Hypnotherapy can be useful. Drug therapy is used only if there is a coexisting anxiety or depressive disorder. Treatment of a comorbid anxiety or depressive disorder with psychotherapy and/or pharmacotherapy may lead to substantial improvement in the conversion disorder. The drugs amobarbital or midazolam may be used as part of a hypnosedative interview in treatment resistant cases. As physically based (organic) illness and conversion disorder may coexist, all individuals with conversion symptoms should be treated as if they have an organic illness. |
Source: Medical Disability Advisor
| Recovery rates range from 15% to 74%. Conversion symptoms are generally self-limited and may resolve within 2 weeks if hospitalization is part of the treatment. While psychotherapy may lead to dramatic recovery in some individuals, recurrence of symptoms is seen in one-fourth of individuals within 1 year of the first episode. Factors associated with good outcome include being male, sudden onset of symptoms, occurrence of symptoms following a stressful event, good health before appearance of conversion symptoms, and lack of accompanying physical or psychiatric disorder. Symptoms of paralysis and blindness have a good prognosis while seizures and tremor have a worse outlook. The longer the individual has been in the sick role and regressed, the more difficult treatment can be. If the individual has other psychopathology or a chaotic social situation, disability can be prolonged. A documented neurological disease may also determine disability. |
Source: Medical Disability Advisor
| Loss of muscle tone or bulk related to not using the affected limb is a rare complication. Individuals may hurt themselves when falling, convulsing, or as a result of "blindness." Conversion disorder may lead to a vicious cycle in which "sick" behavior is reinforced through increased attention, avoidance of responsibility, or other secondary gain. This in turn may lead to worsening of conversion symptoms or development of new ones. |
Source: Medical Disability Advisor
| Work restrictions or accommodations are necessary only infrequently, for the most serious cases. In these instances, time-limited restrictions and work accommodations should be individually determined based on the characteristics of the individual's response to the disorder, the functional requirements of the job and work environment, and the flexibility of the job and work site. The purpose of the restrictions/accommodations is to help maintain the worker's capacity to remain at the workplace without a work disruption or to promote timely and safe transition back to full work productivity. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Has an extensive medical examination ruled out any underlying medical explanation or other cause of the symptoms?
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Was clinically significant distress or impairment in social, occupational, or other important areas of functioning evident or reported by the individual?
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Was diagnosis of conversion disorder confirmed?
Regarding treatment:
- Because a trusting relationship with the physician is essential to treatment, has individual established a good doctor-patient relationship? If not, what can be done to build or restore this relationship?
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If anxiety or depressive disorders are present, are these disorders being effectively addressed with drug therapy?
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If individual is resistant to the idea that symptoms are a result of a psychological problem, would individual be more accepting if behavioral therapy was presented as stress reduction or coping skills for a chronic illness?
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Would individual benefit from a group therapy environment where social support and interaction are used to reduce anxiety?
Regarding prognosis:
- Since a strong positive correlation exists between duration of conversion symptoms and the time required to resolve them, what was the interval between onset of symptoms and start of treatment?
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Has the individual experienced any recurrences that may predict future episodes?
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Source: Medical Disability Advisor
| CitedFrances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000. |
Source: Medical Disability Advisor
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