Conversion Disorders Authors David Choon Liang Teo MBBS

Conversion Disorders Author(s): David Choon Liang Teo, MBBS (Singapore) Level: Basic Academic Affiliation: National Healthcare Group, Resident Version No: 1. 2 Submitted: December 2012 Editors’ Review: April 2013

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4 Learning Objectives • Understanding the definition and epidemiology of conversion disorders • Understanding the clinical presentation of conversion disorders • Understanding the management principles and prognosis of conversion disorders

5 Outline • What are conversion disorders? • Epidemiology of conversion disorders • DSM-IV TR criteria for conversion disorders • Clinical presentations and diagnosis of conversion disorders • Differential diagnosis of conversion disorders • Management of conversion disorders

6 What is Conversion Disorder • DSM-IV TR classifies conversion disorder as a somatoform disorder, while ICD-10 classifies conversion disorder as a dissociative disorder • In conversion and dissociative disorders, there is a loss of motor or sensory function which initially appears to have a neurological cause but is later attributed to a psychological cause • Can be thought of as psychological distress ‘converted’ into physical symptoms • In DSM-IV TR, ‘conversion’ refers to a motor or sensory deficit, while ‘dissociation’ refers to a disturbance in conscious state

7 DSM-IV-TR Diagnostic Criteria for Conversion Disorder A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors C. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering) D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation

8 DSM-IV-TR Diagnostic Criteria for Conversion Disorder (2) F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder Specify type of symptom or deficit • With motor symptom or deficit • With sensory symptom or deficit • With seizures or convulsions • With mixed presentation

9 Epidemiology • 33 % lifetime prevalence in mothers • 25% of patients admitted to general medical services had conversion symptoms some time in their lives • Annual incidence 22 per 100, 000 • Most common in young women, rural areas, uneducated, lower socio-economic classes

10 Clinical Presentation Common Symptoms Motor Sensory Visceral Involuntary movements Anaesthesia Psychogenic vomiting Tics Blindness Pseudocyesis Blepharospasm Tunnel vision Globus hystericus Opisthotonus Deafness Swooning or syncope Seizures Urinary retention Abnormal gait Diarrhea Falling Astasia-abasia Paralysis Weakness Aphonia

11 Clinical Presentation (con’t) • Common to have pre-existing psychopathology – – Depression Anxiety Schizophrenia Personality disorder (histrionic, dependent, passive-aggressive) • May be precipitated by exposure to others with similar symptoms (“figures of identity”) • Careful evaluation imperative to exclude organic illnesses – Negative evidence + Positive evidence – 4% misdiagnosis

12 Differential Diagnoses of Conversion Disorder • Organic – medical or neurological illness • Somatisation disorder – Multiple, recurrent and frequently changing physical symptoms over a lengthy period. Preoccupation with these symptoms leading to marked distress in the patient • Hypochondriasis – Preoccupation with having serious physical illness, despite evidence to the contrary • Factitious disorder / Munchausen syndrome – Intentional feigning of symptoms with an unclear motivation • Malingering – Intentional feigning of symptoms with clear motivation

13 Management of Conversion Disorders • Psychoeducation – Explain to patient that sensorimotor disturbances result from a loss of conscious control over the affected function • Supportive optimism and suggestion that symptoms will gradually improve • Confrontation seldom helpful • Cognitive Behavioural Therapy • Physiotherapy • Pharmacotherapy for any underlying psychiatric disorder

14 Prognosis of Conversion Disorders • Complete remission rate of 50% by discharge in general hospital setting • 20 -25% of patients develop recurrent conversion symptoms within 1 year • Unilateral functional weakness or sensory disturbances in hospitalised neurological patients persisted in > 80% • Patients with 1 conversion symptom may also develop other forms of somatisation or eventually meet the criteria for somatisation disorder

15 Summary • Conversion disorder is a condition in which there is a loss or disturbance of normal motor or sensory function which initially appears to have neurological or other physical cause, but is later attributed to a psychological cause • Important to exclude organic causes for symptoms to avoid misdiagnosis • Important to exclude underlying psychiatric illnesses • Mainstay of treatment is psychoeducation, supportive optimism and suggestion that symptoms will improve

16 Key References and Acknowledgments • Diagnostic and Statistical Manual of Psychiatric Disorders, 4 th Edition, Text Revision (2000), American Psychiatric Association. • Kaplan and Sadock’s Synopsis of Psychiatry: Behavioural Sciences / Clinical Psychiatry, 10 th edition. • Semple D. , Smyth R. Oxford Handbook of Psychiatry, 2 nd edition. Oxford University Press. • Owens C. , Dein S. Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment (2006) 12: 152 -157.

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