Childhood Conversion disorder

Conversion disorder, a mental disorder characterized by the presence of multiple

medically unexplained neurological symptoms and signs precipitated by psychological stress,
occurs in childhood.
Conversion disorder (also known as functional neurological system disorder) is a
condition in which a person experiences physical and sensory problems, such as paralysis,
numbness, blindness, deafness or seizures, with no underlying neurologic pathology. These
problems are serious enough to negatively impact important life functions, such as academic
performance, social relationships and family life.
Pediatric Conversion Disorder
Pediatric conversion disorder is a mental condition where a child has physical symptoms
that can’t be explained by a medical reason.

Background and Nomenclature

The term "hysteria" was attributed either to ancient Egyptians or to Hippocrates and the
Greeks (hysterika is Greek for uterus), with a belief that female ailments could be the result of
a wandering uterus applying pressure internally on organs and nerves leading to symptoms.
In the 17th century, Rene Descartes postulated mind-body dualism, in which mind and
body are distinct substances that could not exist in unity, with the body subject to mechanical
laws, but not the mind. 
By the 19th century, reflex theory asserted that every organ can influence every other
organ, independent of the mind and will.
In the 20th century, thinking was influenced by Freud's psychoanalysis model, and he and
Josef Breuer speculated on possible neurological mechanisms of conversion symptoms and
coined the term "conversion" to signify the substitution of somatic symptoms for repressed
emotions.
In behavioral models, conversion symptoms are viewed as a learned maladaptive
behavior that is reinforced by the environment. Although these theories did not provide an
explanation of the mechanism for conversion symptoms, they highlighted important contextual
factors.
 1952 DSM - Conversion reaction
  1968 DSM-II - Hysterical neurosis (conversion type)
 1980 DSM-III - Conversion disorder
 1987 DSM-III-R - Conversion disorder
 1994 DSM-IV - Conversion disorder
 1994 ICD-10 - Dissociative (conversion) disorder
 2013 DSM-5 - Conversion disorder (functional neurological symptom disorder)
Causes
 Stress and emotional or physical trauma
 Family member with neurological disorder
 Mental health conditions (such as anxiety disorder, dissociative disorder or mood
disorder)
 Sexual abuse or neglect in childhood
 In psychodynamic theory, primary gain refers to the extent to which a conversion
symptom diminishes the unpleasant emotion and anxiety and keeps the conflict internal.
Secondary gain is achieved when the symptom presentation serves to help the individual
avoid the situation generating the conflict. Gaining attention and emotional support from
persons in the environment is an example of secondary gain.
Neuroscience considerations
Some studies hypothesize a multifocal network, including premotor, primary
sensorimotor, superior parietal, cingulate cortex, and cerebellar areas involved in functional
sensory disorders with enhanced cortical and subcortical inhibition in the hemisphere
contralateral to the functionally impaired limb. Similar networks appear to be involved in
enhanced inhibition in the motor system in functional motor paresis symptoms. At present, the
evidence available suggests a broad hypothesis that frontal cortical and limbic activation
associated with emotional stress may act via inhibitory basal ganglia, thalamo-cortical circuits to
produce a deficit of conscious sensory or motor processing.
Signs and symptoms
Conversion disorder involves the loss of one or more bodily functions. Examples include:
 Weakness or paralysis
 Loss of balance or difficulty walking
  Tremors or seizures
 Vision problems, such as double vision or blindness
 Hearing problems or deafness
 Difficulty speaking or inability to speak
 Difficulty swallowing
 Can’t control your movements.

Testing and diagnosis

All of the problems that are signs of conversion disorder can, of course, have medical and
neurological causes and can be signs of significant medical conditions. Although it is through
medical examination that conversion disorder is diagnosed, there are frequently behavioral clues
that conversion disorder is the appropriate diagnosis. For example, symptoms often begin with
maximal intensity, occur only in certain settings or with certain people, and cause more
withdrawal from typical activities than would be seen in children with similar neurologic or
medical disorders. Diagnosis generally begins with medical examination and testing by
appropriate specialists, depending on the problems exhibited. These tests may include simple
reflex checks, X-rays or other imaging, or an electroencephalogram (EEG) scan if the symptoms
include seizures. This medical diagnosis must be done carefully, because the symptoms of
conversion disorder can mimic those of other medical conditions. At the same time, a balance
must be struck to avoid unwarranted invasive tests. In many cases, simple examination methods
can be used to distinguish between problems with a neurological or medical basis from
conversion symptoms.
If the medical and neurological examinations are consistent with a diagnosis of
conversion disorder, the diagnostic team expands to include a mental health provider with
expertise in working with children and adolescents. The mental health provider may help the
family identify thinking patterns, stressors or events that may be associated with the symptoms.
However, with many families, there is no identified underlying stressor, or the stressor(s) take
some time to identify. In these cases, mental health treatment focuses on the young person’s
thinking patterns around his or her symptoms, as well as maximizing the child’s return to full
functioning. The psychological assessment will include a diagnosis of any other mental health
issues that may need to be addressed in a treatment plan.
Comorbidity
Conversion disorder can co-occur with several medical and psychiatric conditions, thus
complicating diagnostic processes that focus on an “exclusion” of the latter. Typical comorbid
diagnoses include mood disorders, panic disorder, generalized anxiety disorder, posttraumatic
stress disorder, dissociative disorders, social or specific phobias, and obsessive-compulsive
disorders.
Differential Diagnosis
If another mental disorder better explains the symptoms, that diagnosis takes precedence.
However, conversion disorder may coexist with other psychiatric conditions, such as:
 Anxiety disorder
 Depressive disorder
 Panic disorder
 Body dysmorphic disorder
 Other somatic symptom disorders
Prevalence
It is more common in rural areas, among uneducated people, and in the lower
socioeconomic classes. Ratio in male and female is 1:3.
Prognosis
Generally, prognosis is supposed to be better in children than in adults with conversion
disorder; follow-up studies indicate eventual full recovery in 85-97% of children. With early
recognition of the nature of the condition and prompt intervention, some recover within a few
weeks or even days of the onset of symptoms. Prognosis is good in cases with monosymptomatic
manifestation and a good premorbid personality and is worse when symptoms have been present
for a long time, with comorbid psychiatric disorders, when there is a history of sexual abuse, and
in multisymptomatic patients. The onset is generally acute, but symptoms may gradually
increase. Generally, in adults, symptoms ameliorate in more than half of all hospitalized patients
with this disorder at the time of their discharge, with a 20-25% relapse rate in one year.
Childhood conversion disorder is believed to be associated with a good outcome; however, in
one series, 15% failed to recover from their conversion symptoms and 35% were eligible for
a DSM diagnosis of mood or anxiety disorder 4 years after diagnosis.
Treatment
The hallmark of effective treatment for conversion disorder is emphasis on returning to
age appropriate functioning. This can begin with reinstitution of regular daily routines, and
return to school and other activities. For young people with weakness, tremor or sensory loss,
additional rehabilitative treatment may be needed. This may include:
Counseling: cognitive behavioral therapy or psychotherapy to address anxiety and thinking
patterns about symptoms, as well as avoidance of any underlying stressors. Counseling may also
be needed to address any co-occurring mental health conditions, such as depression or anxiety.
Physical or occupational therapy: to strengthen and loosen muscles that may have weakened
and tightened through inactivity.
Medications: to supplement the counseling treatment for stress and anxiety and for any
associated mental health conditions.
 References

Brašić, J. R., & Morgan, R. H. (2002). Conversion disorder in childhood. German Journal of

Psychiatry, 5(2), 54-61.British