Conversion disorder
Anna Lethborg, Ashley Quinn & Alicia Grant
Contents
Conversion disorder
Aetiology
Pathogenesis
Diagnostic criteria
Typical presentation
Physio assessment
Outcome measures
EBP of physio treatment
Pt goals
Summary
Questions
Conversion Disorder (CD)
" An alteration or loss of physical functioning
suggestive of a physical disorder that is thought to
be due to a psychological stressor or conflict.” (Ruddy
& House 2010)
Symptoms are not intentionally produced however
may be perpetuated by social support and
avoidance of unpleasant situations.
Prevalence is estimated at ≥ 50 per 100, 000 (Ruddy &
House, 2010)
Pt Presentation
•Hx of psychological condition/stress/medical condition
• ≥ 1 symptom(s) affecting voluntary motor and sensory function, inconsistent with
known neurological or musculoskeletal conditions
•Common symptoms:
• Aphonia, deafness, Vision disturbances (diplopia and blindness)
• Weakness/Paralysis
• Numbness or decreased light touch sensation
• gait disturbances
• Poor coordination or balance
• Difficulty w/ speech & swallowing
• Seizures or convulsions
•Other possible symptoms include: Loss of balance, inability to sense pain,
jerky/exaggerated movements, hallucinations, urinary retention, La belle
indifference
Diagnosis
Testing may include:
Standard neurological and musculoskeletal assessment
Laboratory studies
Imaging
CXR, CT, or MRI
Functional MRI (fMRI) and transcranial magnetic stimulation (TMS) studies have shown different activation patterns
in patients with conversion symptoms and healthy control subjects; this is in keeping with the "involuntary" nature
of conversion symptoms. ()
Key Findings:
Inconsistencies during repeated sensation, and MMT;
muscle strength that doesn’t correlate with functional ability.
sensory changes that don’t follow any dermatomal or peripheral nerve pattern.
Diagnostic criteria
DSM-IV Diagnostic Criteria for Conversion Disorder (300.11)
A. ≥ 1 symptoms or deficits are present that affect voluntary motor or sensory function that
suggest a neurologic or other general medical condition.
B. Psychologic factors are judged to be associated with the symptom or deficit because
conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit.
C. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or
malingering).
D. The symptom or deficit, after appropriate investigation, cannot be explained fully by a
general medical condition, the direct effects of a substance, or as a culturally sanctioned
behavior 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.
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.
(Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Fourth Edition, 2000)
Aetiology
True aetiology is unknown.
Is commonly believed CD is brought on by previous severe stress, emotional conflict, or
an associated psychiatric disorder.
Many studies confirm high incidence of depression in patients with conversion
disorder.
Other groups with higher incidence:
Those personality disorders or hysterical traits ()
Women
1st-degree relative with a medical or psychiatric disorder ()
In children CD is often preceded by physical or sexual abuse, or if a family member is seriously ill
or in chronic pain
Family Hx of conversion disorders
Pathogenesis
2 theories:
Psychodynamic theory: symptoms develop to
protect against abnormal impulses
Learning theory: symptoms are a maladaptive
coping strategy to stress.
PT Ax
History/Background Formal Testing Functional Testing
Current symptoms: Observations: posture, local Bed mobility
aggs/eases signs, trophic changes
Onset Hx/timeline Palpation: tenderness, balance
swelling, spasm, heat
Previous Mx/treatment Movement: active & passive transfers
PMHx Muscle function: tone, power, walking
bulk
Meds Sensation: cutaneous, Gross motor skills: jumping,
proprioception hopping, running, stiars
Social situation: work, school, Co-ordination Fine motor skills
friends and family
Typical day: interests, Self-care: dressing, washing,
hobbies, sleep, self-care feeding, toileting.
Body chart: pain and sensory disturbances
(Brazier & Venning, 1997)
Outcome Measures
Will be based on the:
pt’s presenting signs and symptoms.
Eg. if a patient presents with a weak arm: grade
2+, the outcome measure may be a MMT score.
The patient has a paralysed arm for 3 weeks and
now presents to rehab., an outcome measure may
be feeding themself.
PT treatment overview
Establish a good rapport with the pt, re-
enforce that medical investigations are all
normal.
Educate the pt about secondary problems
such as muscle wastage and that rest will
prolong absolute recovery.
EBP
Psychological Rx alone is not effective in
treating CD (
Recovery of neurologic function is usually
slow and takes place over days, weeks, and
months; it is rarely abrupt. Any recovered
neurologic function is reinforced with
physiotherapy and appropriate physical aids
provided by a physical therapist familiar with
psychogenic neurologic deficits (47).
PT goals
Short term
Long term
Prognosis:
Prognostic studies differ in outcome, with recovery rates ranging
from 15-74%. Factors associated with favorable outcomes are
male gender, acute onset of symptoms, precipitation by a
stressful event, good premorbid health, and an absence of
organic or psychiatric disorder.
Many patients with conversion reactions have spontaneous
remission or demonstrate marked or complete recovery after
brief psychotherapy.
(Binzer & Cullgren, 1998)
References
Binzer M, Kullgren G. Motor conversion disorder. A prospective 2- to 5-year follow-up
study. Psychosomatics. Nov-Dec 1998;39(6):519-27. [Medline].
Brazier DK, & Venning HE (1997). Conversion disorders in Adolesents: A practical approach to
rehabilitation. British Journal of Rheumatology; 36: 594-598
Hurwitz T. (2003). Somatization and Conversion Disorder. Canadian Journal of Psychaitry; 49: 172-179.
Ness D. (2007). Physical Therapy Management for Conversion Disorder: Case Series. Journal of
Neurological Physical Therapy; 31: 3030-39.
Conversion Disorder
Author: Seth Powsner, MD, Professor of Psychiatry and Emergency Medicine, Yale University School
of Medicine; Medical Director, Crisis Intervention Unit, Section of Emergency Medicine, Yale-New
Haven Hospital
Coauthor(s): Susan E Dufel, MD, FACEP, Program Director, Associate Professor, Department of
Traumatology and Emergency Medicine, Division of Emergency Medicine, University of Connecticut
School of Medicine
Contributor Information and Disclosures Updated: May 1, 2009
http://emedicine.medscape.com/article/805361-overview
Watanabe TK, O’Dell MW, & Togliatti TJ (1998). Diagnosis and rehabilitation strategies for patients
with hysterical hemiparesis: A report of four cases. Accademy of physical medicine and rehabilitation;
79: 709-714
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