Conversion Disorder

Conversion Disorder S. Arabzadeh, M.D.

Conversion DisorderDefinition • Deficit in voluntary motor or sensory function • Preceded by conflicts or other stressors • The gain is primarily psychological not social monetary or legal

Conversion DisorderEpidemiology • Ratio of women to men • Range of 2/1 to 10/1 in adults • Increased female predominance in children • Women with conversion symptoms more likely to subsequently develop somatization disorder

Conversion DisorderEpidemiology • Incidence less than 1% of general population • 5 to 15 % of psychiatric consultations in a general hospital • Common age is adolescents and young adults

Conversion DisorderEpidemiology • Onset at any age, but most common in adolescent to early adulthood (rare before 10 years of age, or after 35, but reported as late as the ninth decade of life) • Probability of occult neurological or other medical condition high with onset of symptoms in middle or old age.

Conversion DisorderClinical Features • Motor symptoms • Sensory deficits

Conversion DisorderClinical Features • Most common symptoms • Paralysis • Blindness • Mutism

Conversion DisorderClinical Features • Sensory symptoms • Anesthesiaand paresthesia (extremities) • Distribution of the neurological deficit inconsistent with either central or peripheral neurological disease (e.g. stocking-and-glove anesthesia, and hemianesthesia beginning precisely along the midline) • deafness, blindness, tunnel vision • Unilateral or bilateral • Intact sensory pathways by neurological exam (e.g. conversion disorder blindness: ability to walk around without collision or self-injury, with pupils reactive to light, and normal cortical evoked potentials.)

Conversion DisorderClinical Features • Motor symptom: • Abnormal movements (choreiform, tics, jerks) • Gait disturbance • Weakness • Paralysis

Conversion DisorderClinical Features • Motor symptoms • Movements generally worsen with calling of attention • Reflexes remain normal • No fasciculations/muscle atrophy (except chronic conversion) • Normal electromyography

Conversion DisorderClinical Features • Seizure symptoms • Pseudoseizures • 1/3 of those with pseudoseizures have coexisting epileptic disorder • Tongue biting, urinary incontinence, and injuries after falling can occur (although generally absent) • Pupillary and gag reflexes retained • No postseizure increase in prolactin concentration

Conversion DisorderComorbidity • Depressive disorders (increased suicide risk) • Anxiety disorders • Somatization disorders • Personality Disorders • Medical and especially neurological disorders

Etiology • Repression of unconscious intrapsychic conflict • Conversion of anxiety into a physical symptom • Hypometabolism of dominant hemisphere • Hypermetabolism of nondominant hemisphere Psychoanalytic factor Biological Factor

Conversion DisorderDiagnosis • Ruling out a medical disorder 25—50 % have neurological or nonpsychiatric medical disorder • Can be resolved by suggestion • LA BELLE INDIFFERENCE

Conversion DisorderDistinctive Physical Findings

Conversion DisorderTreatment • Insight-oriented supportive or behavior therapy • Relationshipwith a caring and confident therapist most important feature of the therapy • Reassurance • helping the patient verbalize distress • simple behavioralinterventions

Conversion DisorderTreatment • Presentation of the diagnosis • avoid indirect and fragmentary discussion • naming: non epileptic seizure • Avoid mentioning ‘real’ or ‘unreal’ • Validate the reality of events • Present the result of the tests

Conversion Disorder Management/Treatment • Cause of the disease • We do not know the cause • Symptoms have no clear physical cause • Is not intentionally made • Result from interaction between subconscious mind and body • Role of stress • Need of psychological interview

PSYCHOLOGICAL HELP • Encourage the patient to acknowledge recent stresses • Give positive reinforcement • Take brief rest from stress before returning to usual activities • Advise against prolonged rest or withdrawal from activities • Symptoms usually resolve rapidly leaving no permanent damage

Conversion DisorderManagement/Treatment • Acute cases • Reassurance/appropriate rehabilitation • Resolution usually spontaneous

Conversion DisorderTreatment • Chronic cases • Aggressive therapy of comorbid psychiatric illness • Pharmacotherapy • Anxiolytic or antidepressant medications ? • Psychotherapy

Pharmacotherapy • comorbid psychiatric condition • SSRI • Beta-blockers • Analgesics • Benzodiazepines

Suggestion • psychological process by which one person may guide the thoughts, feelings or behaviour of another • waking suggestions • hypnotic suggestions

Treatment of chronic types • Family therapy • Cognitive behavior therapy • problem-solving techniques • reframing of distortedcognitive beliefs • Counseling • Group therapy • Hypnosis • Psychodynamic approaches • Exploring intrrapsychic conflicts, and the symbolism of conversion symptoms ???

Conversion DisorderPrognosis • Good prognosis • Acute onset • Identifiable stressor • Short interval between onset and treatment • Paralysis • Aphonia • blindness

Conversion DisorderCourse • 95% remit spontaneously • 20-25% Recurrence • 25 to 50% neurological disorders or nonpsychiatric medical conditions affecting the nervous system

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Conversion Disorder