Conversion Disorder With Conceptual and Treatment Challenges

In a clinical case, we reviewed the conceptual, diagnostic, and treatment challenges in a diagnosis of conversion disorder. An examination of the revised DSM-5 criteria for conversion disorder including the current neuropsychiatric understanding of the condition is presented. Therapeutic challenges are highlighted, and treatment options are appraised using the available evidence.

Case

“Molly” is a 39-year-old black woman who presented to the emergency department with complaints of her “throat closing up, body locking up, and falling down.” She reported initially developing “belching fits” lasting 10 minutes and occurring at multiple times daily 2 months prior to presentation. She reported attending an out-of-state emergency department where she reported receiving morphine for an unspecified reason, later confirmed to be back pain. She complained that she had subsequently developed “leg jerking” and denied any allergies or past administrations of morphine. She stated that she had left against medical advice after being offered “no diagnosis.” Her family reported that she went on to have fluctuating leg weakness and was seen to collapse frequently without loss of consciousness or head injuries. The patient recounted episodes in which her eyes would “roll up,” and she would “become blind.” Adding to these symptoms, she reported instances of throat tightening. She reported multiple emergency department visits but admitted to repeatedly discharging against medical advice after undergoing numerous investigations without any diagnoses being offered.

Molly’s vital signs and laboratory findings were within normal limits, and neurological consultation noted no pertinent findings. She was admitted for observation under the Neurology service, and all further investigations were unremarkable, including urine toxicology, CT, MRI, and EEG. A psychiatric consultation was obtained. She reported experiencing dyspnea, palpitations, feelings of doom, paresthesias, and avoiding hospitals. She admitted to being unable to return to work, as she felt numb and collapsed often but always without injury. She stated, “I can feel it, so I avoid sharp and hard things.” When asked about stressors, she reported moving out of state to care for her aging mother. Her sister reported that she had ended a long-distance 3-year relationship with her boyfriend in the months prior to the initial symptoms developing. When asked about the circumstances surrounding the breakdown of the relationship, Molly collapsed onto the edge of the bed but actively avoided hitting the rails.

The patient’s mental state examination results remained stable, but a positive Hoover’s sign was found. She developed “double vision” when the diagnosis of conversion disorder was discussed. Although the patient expressed extreme doubt, her family welcomed the diagnosis in light of her previous high-functioning, recent psychosocial stressors, and lack of clinical findings. Psychoeducation and supportive psychotherapy were provided, and the patient was referred for further outpatient treatment but unfortunately did not follow up despite multiple outreach efforts.

Implications

The diagnosis of conversion disorder is one that can only be made after consideration of the presentation, course, investigations, and treatments that fail to account for symptoms of altered voluntary motor or sensory function with evidence of clinical incompatibility.

The disorder raises questions, including how one may assess the volitional component of symptoms, identify psychological mechanisms where none may apparently exist, and provide a treatment that integrates these uncertainties but provides relief to the patient.

Revision of DSM-5 Criteria

Criteria for conversion disorder in DSM-5 no longer require the identification of psychological factors initiating or exacerbating the voluntary symptom but now require that clinical evidence demonstrate incompatibility between symptoms and any recognized condition. Nonintentional production is no longer a criterion. The revised criteria challenge the original definition, which relied on pseudoneurological symptoms resulting from conversion of an unconscious psychological conflict to somatic representation (1).

The above case underscores the challenges in evaluating and treating patients who do not accept such a diagnosis. Patients who seek multiple assessments and have symptoms that are incompatible to any one condition should be evaluated for possible conversion disorder. Although some hesitate to provide such a diagnosis out of fear of being incorrect, missing another condition, a meta-analysis established the misdiagnosis rate at 4%, similar to that for schizophrenia and amyotrophic lateral sclerosis. The psychiatrist should also consider comorbid disorders, including phobia, anxiety, panic attacks, and trauma-related disorders (2).

Mechanisms of Conversion

Dissociation was initially proposed as a psychological theory for conversion disorder, as it could lead to problems maintaining the normal conscious synthesis of experience (3). Freud proposed a different mechanism whereby unwelcome experiences are repressed into the unconscious but in doing so become converted into physical symptoms. Although the repression was deliberate, the conversion was not (4). The removal of the psychological-basis criterion permits diagnosis whereby a psychological stressor may not be identified but risks its inappropriate application. The new incompatibility criterion supports the use of some evidence-based tests that demonstrate clinical discrepancy but may be unethical with regard to tests that could negatively affect the patient-doctor relationship. The use of placebo to diagnose and treat conversion disorder has been critiqued for similar reasons (5).

Researchers have examined the etiology of conversion disorder, and evidence by Black et al. (6) suggests that during conversion reactions, primary perception remains intact, with modulation of sensory and motor planning becoming impaired through disruption of the anterior cingulate cortex, orbitofrontal cortex, and limbic brain regions. Furthermore, limited functional imagining findings suggest that frontal, cortical, and limbic activation associated with emotional stress may act via inhibitory basal ganglia-thalamocortical circuits to produce a deficit of conscious sensory or motor processing (7).

Cultural Factors

Somatization, as a culturally defined phenomenon, has been understood to be a channeling of distress into physical symptoms through the idiom of distress hypothesis (8). Somatization in collectivistic cultures may be a constructive response to psychosocial stressors, whereas in individualistic cultures it may be disadvantageous because it is inconsistent with the value of direct expression. Somatization can hinder others’ recognition of the individual’s distress, leaving the individual without help. The patient in the above case was born to Jamaican parents but raised in the United States. Her experience of identifying as American with immigrant parents raises questions about the validity of such cultural delineations as either collectivist or individualistic.

Ongoing Challenges

Conversion disorder remains a diagnosis of exclusion. Patients may express doubt, anger, and disappointment or seek different providers, which negatively affects the doctor-patient relationship. Psychoeducation helps patients accept their symptoms as real, validates the diagnosis, and allows for treatment. Although patients exhibit short-term resolution with reassurance, more than 25% relapse (9). Patients’ perception of health and functioning is correlated with resolution, suggesting that interventions should focus on improving function and self-esteem.

Prospective and controlled data examining treatment for conversion disorder remain limited. Current literature supports a multidisciplinary approach with interventions including cognitive-behavioral therapy and psychodynamic therapy to address underlying symptom formation. Hypnosis may prove useful in diagnosis and treatment if its purpose is explained. Once in a trance-like state, patients may be directed to turn the symptom on and off. Symptoms may be improved using antidepressants, anxiolytics, or other psychotropics, depending on psychiatric comorbidity. The use of specific pharmacological agents, ECT, or transcranial magnetic stimulation for conversion disorder currently lacks quality evidence (10).

Conclusions

Further research is needed to investigate the etiology of conversion disorder and its treatment. We continue to have limited understanding of this contemporary nonvolitional, and at times psychological and symptom-incompatible, disorder and unfortunately lack evidence-based treatments for the patients it affects.

Key Points/Clinical Pearls