Who is most likely to develop conversion disorder?
BackgroundConversion disorder (Functional Neurological Symptom Disorder) is categorized under the new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) category of Somatic Symptom and Related Disorders. [1] It involves symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition. Yet, following a thorough evaluation, which includes a detailed neurologic examination and appropriate laboratory and radiographic diagnostic tests, no neurologic explanation exists for the symptoms, or the examination findings are inconsistent with the complaint. In other words, symptoms of an organic medical disorder or disturbance in normal neurologic functioning exist that are not referable to an organic medical or neurologic cause. [2] Show Common examples of conversion symptoms include blindness, diplopia, paralysis, dystonia, psychogenic nonepileptic seizures (PNES), anesthesia, aphonia, amnesia, dementia, unresponsiveness, swallowing difficulties, motor tics, hallucinations, pseudocyesis and difficulty walking. Reports of less common manifestations of conversion disorder abound in the literature and include camptocormia, clenched fist syndrome, recumbent gait, odd vocalizations, and pseudo foreign accent syndrome. [3, 4, 5, 6, 7] Multiple symptoms suggest a somatization disorder. Conversion disorder is a type of somatoform disorder where physical symptoms or signs are present that cannot be explained by a medical condition. Very importantly, unlike factitious disorders and malingering, the symptoms of somatoform disorders are not intentional or under conscious control of the patient. This can be difficult to ascertain during the initial history and work up of the patient. See the image below.  Case studyA young woman’s family brings her to the hospital and she presents with a chief complaint of “spells.” It seems that over the past several weeks, the patient has suffered from attacks of bilateral arm jerking, followed by bilateral leg jerking after she lowers herself to the floor. Often, her head shakes violently side to side and her eyes are seen to "roll back in her head" followed by forced eye closure. These incidents follow episodes of emotional outbursts, and the patient is fortunately able to warn others that “I’m about to have a seizure!” After hearing this, her family grabs the patient and places her in a chair or on the ground until the spell is over, which sometimes can wax and wane for 20-30 minutes with varying intensity. These spells are not accompanied by loss of bladder or bowel continence, but often the patient bites the tip of her tongue and kicks over tables or strikes family members during an episode. This most recent spell occurred while the patient was driving her car, in which she warned of an impending seizure and pulled the car to the shoulder just before losing consciousness; her spell was much more intense than she has had in the past. She has no significant past medical history and takes no medications. She reports a past history of childhood sexual abuse from a paternal uncle several years ago. On exam, her vital signs are normal and her neurologic evaluation is without significant findings. She is not orthostatic. Laboratory work-up, including urine toxin screen, is negative. PathophysiologyConversion symptoms suggest a physical disorder but are the result of psychological factors. According to the psychodynamic model, the symptoms are a consequence of emotional conflict, with the repression of conflict into the unconscious. In the late 1880s, Freud and Breuer suggested that hysterical symptoms resulted from the intrusion of "memories connected to psychical trauma" into the somatic innervation. This mind-to-body process was referred to as conversion. Others have introduced attachment theory as a means to understanding conversion disorder in terms of the freeze response and the appeasement defense behavior seen in animal subjects. [8] The patient has been postulated to derive primary and secondary gain. With primary gain, the symptoms allow the patient to express the conflict that has been suppressed unconsciously. With secondary gain, symptoms allow the patient to avoid unpleasant situations or garner support from friends, family, and the medical system that would otherwise be unobtainable. According to sociocultural theories, the direct expression of emotions is impermissible and somatization takes its place. In behavioral models, conversion symptoms are viewed as a learned maladaptive behavior that is reinforced by the environment. The idea that conversion disorder does not have an organic basis has become entrenched. However, some evidence supports the opposite notion. A review of imaging correlates in patients with motor and sensory conversion symptoms is referenced. [9, 10] Studies on the natural history of conversion disorder indicate that many patients subsequently develop or are found to have preexisting neurologic disease. In fact, conversion disorders may be more frequently observed in patients with a past history of a central nervous system injury. The simultaneous occurrence of organic brain disease with conversion symptoms is also observed, most notably in observation of high rates of organic seizure syndromes associated with psychogenic nonepileptic seizures (PNES). Familial studies have also shown that conversion symptoms in first-degree female relatives are up to 14 times greater than in the general population. That the diagnosis of a conversion reaction or disorder represents a failed diagnosis of an organic syndrome, perhaps with psychogenic overlay that obscures exam and other findings is a valid concern. A recent meta-analysis including more than 1400 cases with follow-up over 5 years reported missed organic diagnosis rates of less than 5%. [11] This correlates with similar reports for the diagnosis of motor neuron disease or schizophrenia. [12] Past rates of misdiagnosis were reported as considerably higher. [11] EpidemiologyFrequencyStefansson et al report that the annual incidence of conversion reactions is 22 cases per 100,000 persons per year in Monroe County, New York. However, the reported rates vary widely. [13] 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 neurologic symptoms. A report by Carson found that 30% of patients at a neurology clinic had "unexplained symptoms." [14] Older reports have estimated that up to 20% of all patients in neurologic clinic settings have symptoms of conversion. [15] Population estimates on incidence range from 4 to 12 cases per 100,000. [16] Overall, conversion disorder is reported to be more common in rural populations, in individuals with lower socioeconomic status, lack of education, and low psychological sophistication. [17] The increased rate of conversion in patients with a past history of sexual or physical abuse is well described. [18, 19] Women are more commonly diagnosed with conversion disorder. [20] Stefansson et al report that the annual incidence is 11 cases per 100,000 persons per year in Iceland. [13] Mortality/MorbidityIndividual conversion symptoms are generally self-limiting and do not lead to physical changes or disabilities. In the case of PNES, patients may have driving privileges removed by medical practitioners and may self-limit other activities due to concern over having a paroxysmal event. The symptoms related to the conversion disorder may lead to decreases in quality of life if they are perceived as egodystonic. Morbidity is often an iatrogenic manifestation of unnecessary diagnostic or therapeutic interventions aimed at establishing an organic diagnosis for the patient's symptoms. Patients with chronic conversion symptoms rarely may develop atrophy, frozen joints, and contractures from disuse. Sex- and age-related demographicsClassically, the female-to-male ratio is 2-10:1. Recent work with PNES reports that males make up approximately 40% of cases. This is a departure from past work, where females made up 80% of cases of PNES in some series. [21] Overall, female-to-male ratio is variable, but the occurrence of conversion disorder is likely higher in females overall. [20] The typical onset is between the second and fourth decades. The reported range is from children to individuals in their ninth decade of life. PrognosisPrognosis is generally poor, although presentation at a young age and early diagnosis in the course of the conversion symptoms are reasons for significant optimism. [22]
Patient EducationSensitively review the disorder with the patient and the family in such a way as to not place blame. During such follow-up for review of completed imaging and other studies, continue to emphasize the importance of pain or other symptoms that the patient may be having. Continue to reassure the patient that the negative test results are good news and bode well for their eventual recovery. Frequent brief office visits to ensure the expected resolution of their symptoms may be helpful. Websites that may provide further information and support for patient and family education include the following:
Author Coauthor(s) Specialty Editor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Additional Contributors Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center Disclosure: Nothing to disclose. Alexis Llewellyn, PhD Licensed Psychologist and Owner, Katy Center for Psychology and Counseling Services Alexis Llewellyn, PhD is a member of the following medical societies: American Psychological Association Disclosure: Nothing to disclose. Acknowledgements The opinions expressed in this work belong solely to those of the authors. They should not be interpreted as necessarily representative or endorsed by the Uniformed Services University, The United States Army, The Department of Defense, or any other agency of the federal government. Who is most likely to get conversion disorder?Conversion disorder is relatively common, with women more likely to experience the condition than men. It can affect people of any age, but tends to be more common between the ages of 20 and 50. Symptoms of conversion disorder may be worrying to experience but they do not pose any long-term threat to health.
What factors are associated with the onset of conversion disorder?Causes and Risk Factors
Conversion disorder may also be a psychological reaction to a highly stressful event or emotional trauma. For example, a soldier who subconsciously wishes to avoid firing a gun may develop paralysis in their hand.
Is conversion disorder more common in men?Occurrence of conversion disorder was found to be higher in females (62.0%) than in males (38.0%) in our study.
What age does conversion disorder appear?During childhood, conversion disorder occurs most commonly in the 10–15 year age bracket and the condition is roughly twice as common in girls as it is in boys. In most cases symptoms date from a minor illness or injury.
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