Author(s): Antonio Quidgley-Nevares, MD, Justin Faye, MD, Eben Alexander IV, DO, Michael Guju, MD, Roberto Austin
Originally published: November 27, 2012 Last updated: June 16, 2022
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Disease/ Disorder

Definition

Conversion disorder (CD) is a condition now also referred to as Functional Neurological Symptom Disorder (FNSD) classified in DSM-5 as related to Somatic Symptom Disorder (SSD).  Other conditions in this category include Medically Unexplained Symptoms, Pain Disorder, and Factitious Disorder.  CD/FNSD presents with motor and/or sensory symptoms initially suggesting identifiable neurologic pathology as the potential cause. However, subsequent diagnostic evaluation fails to reveal neurological disease as the etiological explanation for the symptoms.1 When CD/FNSD presents primarily as an abnormality of voluntary movement—either a lack or an excess of movement—the term Functional or Psychogenic Movement Disorder (PMD) has been employed.  Presentation is typically acute in onset and symptoms may develop consequent to a psychologically conflictual situation although anticipated psychological distress linked to the potentially ominous somatic symptoms may not be evident. A source of psychological conflict may or may not be disclosed.  More often, symptoms occur in the context of an undisclosed underlying psychological conflict, unmet need or harrowing traumatic experience(s) precipitating overwhelming anxiety that obstructs direct verbal disclosure.  As such, symptoms may be interpreted in a biosemiotic framework as the product of a less direct but more attainable subconscious process for communicating a meaningful plea for medical remediation.2-4  In contrast to Factitious Disorder (FD), symptoms are not simulated through conscious intention in CD/FNSD, although specific symptom form and plausibility may be influenced by the patient’s prior experiences, degree of medical sophistication, and cultural background.  The clinical distinction between CD/FNSD and the consciously simulated symptomatology of FD is difficult and can often only be definitively made with a confession of deceit or when the patient is caught out in a broader deception or with covert surveillance.5  When, in addition to being aware of willful simulation of symptoms, the patient consciously intends the presentation of symptomatology for the purpose of tangible secondary gain, then the patient meets criteria for a diagnosis of malingering.

A partial list of more common CD/FNSD symptoms includes paralysis or paresis, involuntary movements, abnormal gait, blindness, sensory alteration, and psychogenic nonepileptic seizures (PNESs).

Diagnostic criteria (all must be met) for CD/FNSD based on the DSM-5 include:

  • One or more symptoms of altered voluntary motor or sensory function.
  • Clinical findings providing evidence of incompatibility between the symptom(s) and recognized neurological or medical conditions.
  • The symptom(s) or deficit(s) are not better explained by another medical or mental disorder.
  • The symptom(s) or deficit(s) cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, and/or warrant medical evaluation.

It should be noted that the diagnosis of CD/FNSD does not definitively exclude the possibility of coexistent and potentially overlapping organic disease.

Etiology

Etiologic perspectives include psychodynamic, behavioral, and neurophysiologic formulations.  Breuer and Freud used the term ‘conversion’ to describe a process through which the ‘unbearable affect’ of existential anguish linked to a repressed upsetting psychological conflict overflows or ‘converts’ into somatic symptoms symbolically and implicitly (i.e.. nonverbally) referencing the source of the internal dissonance. This ‘as-if’ mode of indirect communication then leads to a subconscious emotional decompression, diffusion of affect and resultant ‘escape’ from the original overwhelming provocation—the patient is released from the bind of having a pressing issue about which they long to communicate but cannot.6 Others view CD/FNSD as a rational but maladaptive learned behavior that facilitates coping with an otherwise intolerable situation.7

Anxiety reduction is the adaptive primary gain. Empathic response bestowed and attention given by worried friends and family as well as concern from medical personnel regarding possible physical illness or injury can reinforce the subconscious motive and become a source of fortifying secondary gain.

Epidemiology including risk factors and primary prevention

Epidemiologic studies are limited by inconsistencies in case definition (e.g., medically unexplained physical symptoms vs true CD/FNSD) and inaccurate case ascertainment. Some associated factors are given in Table 1.

Table 1.  Epidemiology of CD/FNSD

Overall incidence rate4-12 / 100,000
In general hospital patients5 – 14%
In psychiatric clinic patients5 – 25%
In neurology clinic patients~6%
Gender RRR in adultswomen:men = 2:1 to 6:1
Gender RRR in childrengirls:boys = 1:1
History of sexual abuse8Up to 33%
History of physical abuse8Up to 50%
Associated factors seen in adult malesAntisocial personality disorder; occupational injury; severe combat stress.
Most frequent age at initial onsetBetween 2nd and 4th decades

RRR: relative risk ratio

An increased incidence in relatives of probands with CD/FNSD has been reported suggesting a genetic predisposition.  Psychogenic seizures may occur in up to one fifth of patients referred for assessment to an epilepsy treatment center.9

A large meta-analysis of case-control studies examined the history of stressful life events and maltreatment in CD/FNSD. The study established increase OR of CD/FNSD given certain history of maltreatment.10

 OR vs controls (CI)
Emotional neglect5.6 (2.4-13.1)
Sexual abuse3.3 (2.2-4.8)
Physical abuse3.9 (2.2-7.2)

 OR: Odds ratio

Patho-anatomy/physiology

Functional neuroimaging studies suggest impaired communication between brain systems linking emotion to volition, movement, and perception, suggesting a mechanism through which elevated anxiety may be converted into physical symptoms.11 Patients with motor CD/FNSD show increased responsivity and reduced habituation in the amygdala to emotionally provocative stimuli. An abnormally strong functional linkage between the amygdala and the supplementary motor area (SMA) of the nondominant right hemisphere has been identified in functional neuroimaging.12 The SMA is involved in voluntary movement selection and the regulation of internally generated action.  A recently published systematic review and meta-analysis of neuroimaging studies in CD/FNSD patients reports that multiple ‘areas that are important for motor-planning, motor-selection or autonomic response seem to be especially relevant.13

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

As noted, onset is frequently correlated with acute psychologic stress or a personal social crisis associated with discordant home life.

Symptoms may be dramatic and can demonstrate variable intensity depending on who is attending to them.  For the majority of cases, the acute condition is self-limited, and symptoms resolve within a few hours to a month with reassurance and intensive supportive counseling.  Chronicity may relate to severity and persistence of the underlying stress, untreated superimposed or coincident psychiatric difficulties, the comorbid presence of a personality disorder, or continuing environmental reinforcement.

Specific secondary or associated conditions and complications

CD/FNSD is a diagnosis to be entertained only after excluding an organic etiology for the symptoms. In less than 5% of cases, an organic condition eventually surfaces.14 Psychiatric comorbidities, including axis I psychiatric conditions (eg, mood disorder) and axis II personality disorders (eg, passive-aggressive/dependent), are frequently seen.15 Patients usually deny emotional difficulty, and resist psychodynamic formulation and psychiatric consultation. Over-aggressive pursuit of a medical explanation with multiple diagnostic tests or initiation of inappropriate medical treatments can precipitate iatrogenic complications.

Essentials of Assessment

History

A comprehensive psychosocial history is critically important. Developing stressors or historical traumatic experiences may be disclosed if a trusting patient-practitioner relationship can be established. A detailed comprehensive history can identify if there may be a viable organic etiology to be considered and excluded. History can mirror symptom severity and the extent to which symptoms currently interfere with daily function.  Besides CD/FNSD, conversion symptoms can be seen in conjunction with other clinical conditions including somatization disorder, substance abuse, affective disorder, and can overlap with co-morbid organic neurologic or medical illnesses.

Physical examination

Physical examination with attention to mental status and neurologic signs should be completed. The distribution and type of impairment often is not homogeneous with neuroanatomical pathways. Incompatible findings on formal examination and behavior in functional situations occur. For example, a patient who is unable to lift an upper extremity during the examination may do so while grooming. Specific signs (eg, Hoover’s sign, give-way weakness, contralateral sternocleidomastoid weakness) can help distinguish organic impairment from functional illness but cannot differentiate between CD/FNSD and malingering. Pathologic reflexes indicate organic etiology.  Patients may overstate or functionally heighten manifestations of underlying organic pathology further complicating the assessment and adding to variability of clinical observations across different examiners.

Functional assessment

Observation of gait and mobility show inconsistent limitations and sometimes bizarre or incongruent non-physiologic patterns of motor impairment. Patients may show blunted or conflicting emotional responses of indifference/preoccupation regarding implications of reported symptoms.  Insight and judgment are often diminished or impaired.

Laboratory studies

Laboratory studies should be judiciously utilized to exclude organic causes. Sensory-evoked potentials can document normal physiologic pathway transmission. With PNESs, electroencephalography with simultaneous video monitoring may be considered, although a normal result does not exclude organic seizures. A prolactin level drawn 30 minutes after a seizure is elevated after organic, but not after nonepileptic seizures.

Imaging

Normal imaging of the brain and spinal cord can help eliminate organic conditions or developing pathology, such as multiple sclerosis/neoplasm.

Supplemental assessment tools

Purification or purgation of emotions during a patient-therapist exploration of repressed experiences and associated affect while the patient is under the influence of an anxiolytic medication, typically benzodiazepine, was once a common treatment for CD/FNSD.16 However, well designed studies to definitively determine efficacy as well as circumstances and methods favoring the success of this intervention are lacking.

Early predictions of outcomes

Between 50% and 90% of CD/FNSD patients exhibit rapid resolution of symptoms after reassurance, although as many as 25% then relapse or develop new conversion/neurologic symptoms over time.17 Longer duration of symptoms, expectation of nonrecovery, untreated psychiatric comorbidity, tremor and/or nonepileptic seizures at the time of initial consultation are associated with worse prognosis.

Environmental

Environmental factors play an important role in the development of CD/FNSD. Considerable psychogenic illness occurs when CD/FNSD develops simultaneously or acutely in multiple individuals in an isolated social environment, with mutual environmental stressors, and a rapid spread of the problem to others through relational networks are common contributing factors.18

Social role and social support system

The depth and breadth of the individual’s relational communication and support matrix (including intrapersonal, interpersonal, and sociocultural factors) determines a patient’s timeline regarding seeking assistance/participation in recommended treatments.  And to some extent, the eventual functional outcome and prognosis.

Professional Issues

Variance between patient and practitioner may result from disagreement regarding etiology. Persisting symptoms can incite feelings of powerlessness, mistrust, as well as provider frustration, which can impair therapy.19 Owens and Dein emphasized the importance of not labeling patients as manipulative, dependent or as exaggerating their difficulties, in order to preserve a functional therapeutic alliance.20 Avoid confronting and appeasing the patient with unnecessary interventions.  Assume an empathic approach that affirms symptom credibility while focusing on a course of practical and functional improvement measures, rather than an extensive search for an elusive organic explanation. Take care in discussing the diagnosis with the patient.19

Rehabilitation Management and Treatments

Discussing the diagnosis

The first step of management is appropriately addressing this new diagnosis and educating the patient and the family on the findings of the work up. It is in the patients’ best interest to tactfully educate them on their diagnosis as well as their prognosis. When patients do not believe that their illness is psychological/functional in nature and when they do not believe they are going be able to recover, patients are twice more likely to have poor outcomes at a year after diagnosis. 21 Many authors have given different versions of how to deliver this diagnosis as patients can be sensitive to accepting it.

It can be helpful to reiterate the test results, state that it is a good thing that no stroke, seizures, or other abnormalities were found on testing. Reassure the patient that the symptoms they are experiencing are real and that they will need to receive follow up for these symptoms from some combination of neurology, psychiatry, psychology, physical therapy, occupational therapy and physiatry since they have “what is called a ‘functional neurological disorder’ or ‘FNSD.’” The clinician should explain that many patients with FNSD have been found to have a history of trauma or abuse in their past and that it why it will be important to include psychiatry and psychology in on the team to help them fully address the roots of their symptoms. Reassure the patient that even though there was nothing observed on imaging, that does not mean that these symptoms are not real. Therefore, follow up is important.22

Given the nature of this disorder, acceptance and understanding can take a while. For this reason, educational materials provided to the family are beneficial.22

Many clinicians may be inclined to not bear the burden of informing the patient of their diagnosis for fear of imparting the stigma of mental disorder on the patient and documenting as such. However, delaying the delivery of this diagnosis will result in unnecessary medical costs, multiple opinions from subsequent clinicians, and worse patient outcomes.21,22

Pharmacotherapy

Currently, the diagnosis of FNSD is not specifically an indication for any pharmacotherapy. No placebo-controlled randomized trials exist to date. Evidence for antidepressants only comes from a few uncontrolled studies.22-24 However, conditions related to FNSD should be treated. For example, if the patient has underlying depression, anxiety, or seizures, then those conditions should be treated. Although there is a high correlation between psychiatric disorders and FNSD, psychogenic medication only has anecdotal evidence of efficacy. If it has been confirmed that psychogenic non-epileptic seizures are not superimposed on a seizure disorder, then anticonvulsants should be withdrawn. If the patient is on a moderate to high dose of these medications, it would be prudent to slowly taper these medications off unless the anticonvulsant is serving as a mood stabilizer.25

Psychological Therapy

Cognitive behavioral therapy (CBT) has been shown to be effective in the treatment in functional neurological disorders to include psychogenic non-epileptic seizures.22 CBT uses strategies between a therapist and patient to give them techniques relevant to their daily life that they can progressively implement with a goal of becoming more autonomous with these strategies.

Physical and Occupational Therapy

Benefit has been noted for as long as a year after three weeks of inpatient physical therapy (PT) and occupational therapy (OT).26 This was assessed in a randomized control trial with 60 patients with a disabling walking gait who had been experiencing symptoms for 1-48 months. Patients exhibited a statistically significant lasting increase in FIMS score, decreased need for assistive devices, and increased physical quality of life at 12 months. The interdisciplinary team consisted of physician, PT, OT, nurse, and adapted physical activity educator, but no psychologist. It should be noted that a core component of cognitive behavioral therapy (CBT) involves rewarding good behavior. This makes it more nuanced to separate the benefits of physical and occupational therapy from CBT.26

The guiding principle behind physical treatment in FND is Skinnerian Theory (a pioneer in CBT) in which disadvantageous behavioral and functional strategies are discontinued, and advantageous ones are encouraged and rewarded.27-31 Rewards can include praise or ability to ambulate around the unit once they have demonstrated sufficient proper technique.27

Patient exercise progression should be stepwise and incorporate increasingly challenging movement tasks as used with analogous neurological disorders.27,32,33 The progression would proceed as follows: establish rapport, engage in bed mobility and general strengthening, then progress to walking in the parallel bars, followed by open spaces, and eventually ambulating in the community.

The need for inpatient versus outpatient therapy should be evaluated similarly to individuals without a functional neurological disorder based on requirements for inpatient rehabilitation.

Staffing changes should be kept to a minimum to foster an environment of increasing rapport and trust.

Coordination of care

Effective treatment of CD/FNSD is best undertaken with a multidisciplinary team in the context of an integrative relational model implementing a collaborative program, recognizing that comprehensive treatment requires interdisciplinary collaboration providing holistic patient-centered care.34

Patient & family education

Transparent treatment includes education of the patient and caregivers regarding the nature of the problem and its management.  This includes constructive explanations of physical symptoms linked to strategies for reducing their functional impact.35 It is important to ensure that caregivers are aware of how they can assist the patient by reinforcing progress toward independence rather than rewarding symptom manifestation.

Families provide essential roles in participating in the patient’s formal PT/OT in order to carry over the progress made during therapy into the patient’s home environment. Family members will also be able to learn by example of therapists demonstrating to ignore unwanted behavior and reward desired behavior.

Emerging/unique interventions

Standardized health status questionnaires and symptom inventories can assess outcomes. Depression scales and anxiety measures can help assess psychiatric comorbidity.   The use of a scale to assess occurrence of stressful life events can help to identify associated sources of stress.36 Measures of health care utilization can assess reduced dependence on provider services.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Intravenous sedative (e.g. Thiopental) may help induce revelation of a major disruptive and actively repressed conflict or trauma.
  • Insight-oriented psychotherapy or short-term cognitive-behavioral therapy in conjunction with conventional rehabilitation therapies can be of benefit.
  • More resistant chronic cases may require strategic double-bind behavioral therapy.
  • Care should be patient-centered, multidisciplinary and collaborative, creating an expectation for recovery and return to full independence.
  • Keep the focus on pragmatic recovery of meaningful function with the expectation for functional improvement and effective symptom management in spite of not being able to determine a specific causative mechanism.
  • Pay attention to contributing environmental and contextual psychosocial factors.

Cutting Edge/ Emerging and Unique Concepts and Practice

Cutting edge concepts and practice

Smith and Dwamena proposed a comprehensive approach to patients with MUPSs, including CD.37 Patients are classified according to 3 dimensions: symptom severity (mild, moderate, and severe), duration (acute, subacute, and chronic), and comorbidity (psychiatric, medical, or both).  Clinical management decisions, such as the extent to which one should pursue diagnosis of an underlying organic disease, can then be guided by this scheme.  The authors propose that this approach facilitates successful and cost-effective symptom management.

Recent research suggests distorted interoception and a disturbance involving the ‘sense of body ownership’ and ‘sense of agency’ in patients with CD/FNSD.  Patients demonstrate reduced interoceptive-based bodily awareness with a retained sense of body ownership similar to dissociative disruption seen in other disorders of self-awareness, embodiment and agency.  Other studies suggest that it is the sense of agency that is impaired in PMD as evidenced by decreased action-effect binding.

Transcranial magnetic stimulation

In 2014, a systematic review was performed by Pollak et al. of the use of Transcranial Magnetic Stimulation (TMS).38 They looked at ten publications that addressed the effects before and after the use of TMS in 95 patients with medically unexplained physical symptoms (MUPS). The authors concluded that despite most of the individual studies reporting TMS as a successful treatment, that this conclusion could, in fact, not be made. Pollack et al concluded this due to lack of placebo controls, subjective outcome measures, transient effects, a low threshold to deem success (often less than 50% improvement in functional outcome measures), inadequate volume of TMS to produce neuromodulation and inappropriate placement of stimulation for effective neuromodulation. They posit that most of the studies were insufficient, and that there was too much heterogeneity in the studies to perform an appropriate meta-analysis determining effectiveness one way or the other.

Difficulty with studying FNSD

FNSD is difficult to study for various reasons. Primarily, there are many different types of FNSD – motor, sensory, dissociative, epileptic, etc.39 Treatment requires a multidisciplinary approach, which makes studying individual therapies difficult.40 There is also an ethical issue of using a randomized control trial for the patients receiving placebo – is it appropriate to place individuals in a placebo group? If so for how long? Additionally, the lack of consistency in nomenclature over the years adds complexity to systematic review on the topic. The various terminology used by the different versions of the Diagnostic and Statistical Manuals (DSM) as well as International Classification of Diseases include functional neurological disorder, conversion disorder, psychogenic non-epileptic seizures, and hysteria.40,41

Gaps in the Evidence-Based Knowledge

Individuals suffer from illness understood as a disturbance in their self-perceived or subjective state of well-being and embodiment.42 This disturbance develops in the context of meaningful and significant social relationships and an internal enculturated belief system framing what the illness experience means to them, how it is perceived, and evaluated within personal (i.e. intrasubjective and intersubjective) context.2,3,43 Medical practitioners diagnose and treat diseases, in the context of pathological disturbances  affecting function and/or structure of body organs and systems as a whole. The reduction of higher level structures into a pure or simpler term  is inadequate  and often misleading in addressing CD/FNSD and related SSDs.44 Eisenberg recommended that “it is essential to reintegrate ‘scientific’ and ‘social’ concepts of disease and illness as a basis for a functional system of medical research and care.”45 A thoughtful  post-modern  foundation that  surpasses mind-body Cartesian qualities  and consolidates  the entire subjective social  experience with the objective scientific perspective has been proposed for improving treatment of psychosomatic conditions.46

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Original Version of the Topic

Gary Goldberg, MD. Conversion disorder. 11/27/2012

Previous Revision(s) of the Topic

Gary Goldberg, MD. Conversion disorder. 3/27/2017

Author Disclosure

Antonio Quidgley-Nevares, MD
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Justin Faye, MD
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Eben Alexander IV, DO
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Michael Guju, MD
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Roberto Austin
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