Dr. M.

Nasar Sayeed Khan

CONVERSION Associate Professor
DISORDER Queens University
[email protected]
The Case of Anna O.
 • Conversion disorder
Somatofor • Hypochondriasis

m •
•
Somatization disorder
Body dysmorphic disorder
Disorders • Pain disorder
 Definition
…taking the form of soma (w/
implication of non somatic)
…”unexplained disorders”

• A broad group of illnesses with

bodily signs and symptoms as the
predominant focus, influenced by
Somatoform the psyche
• Concept of mind/body interactions,
Disorders with signals from the brain (?
mechanism) indicating a problem
• Not based on theoretical construct
or laboratory findings-no
significant substantiating data, yet
vigorous and sincere complaints
“not imaginary”
 • An illness of symptoms or
deficits affecting voluntary
motor or sensory functions,
suggesting another medical
condition, but judged due to
Conversion psychological factors because
of preceding conflicts or other
Disorder stressors.
• Symptoms or deficits are not
Definition intentionally produced, not due
to substance, and not limited to
pain or sexual symptomatology.
• Gain is primarily psychological,
and not social or monetary or
legal.
 • A disturbance of bodily function
not conforming
to current concepts of neurological
anatomy and physiology:
– Characterized by the presence

Conversion of one or more neurological

symptoms, unexplained by a
known neurological or medical
Disorder disorder;
– Typically occurring in a
Definition setting of stress, and producing
considerable dysfunction;
– Requiring for diagnosis the
association of psychological
factors, present at the initiation
or exacerbation of symptoms.
 • A disorder stemming from early
concepts of hysteria:
– Sigmund Freud introduced
Conversion the term conversion (based
on his work with Anna O);
Disorder and
– Hypothesized that the
History symptoms of conversion
reflect unconscious conflict.
 • DSM-V conversion
d/o=dissociative d/o termed as
Conversion functional neurological
Disorder disorders and as conversion and
dissociative in ICD-10
Comparative • Comorbid dissociative d/o in
approximately 30% of
Nosology inpatients with DSM-V
conversion disorder/FND
 • Some symptoms, but not severe
enough to warrant diagnosis in
1/3 of general population at
some time
• Lifetime risk by some studies
Conversion of 33% for either transient or
Disorder longer-term disorder
Epidemiology • 25-30% of admissions
• Range in general population of
11-300/100,000
• DSM-V range of 1-500/100,000
 • Estimate of 20-25% admitted to a general
medical service with conversion symptoms
at some time during life
– Engel GL. Conversion symptoms. In:
MacBryde CM, ed. 5th ed. Signs and
symptoms: applied pathologic
physiology and clinical interpretation.
Philadelphia: JB Lippincott, 1970:650-

Conversion •
68.
5-16% on several psychiatric consultation

Disorder
services referred for assistance in diagnosis
and management of conversion symptoms
– Lazare A. Hysteria. In: Hackett TP,
Epidemiology Cassem NH eds. MGH handbook of
general hospital psychiatry. St Louis:
CV Mosby, 1978:117-40.
• 24% in 500 psychiatric outpatients with at
least one conversion  symptom
– Guze SB, Woodruff RA, Clayton PJ.
Am J Psychiatry. 1971;128:643-6.
 • Ratio of women to men
– Range of 2/1 to 10/1 in adults
– Increased female
predominance in children
• Symptoms in women more
Conversion •
common on left side of body
Women with conversion symptoms
Disorder more likely to subsequently
develop somatization disorder
Epidemiology • Association in men between
conversion disorder and antisocial
personality disorder
• Men with conversion disorder
often involved in occupation or
military accidents
 • Onset at any age, but most
common in late childhood to
early adulthood (rare before 10
years of age, or after 35, but
reported as late as the ninth
Conversion decade of life)
• Probability of occult
Disorder neurological or other medical
Epidemiology condition high with onset of
symptoms in middle or
old age.
 • Common Prototypes
– Rural populations
– Developing nations and
regions
– Persons with limited education
and medical knowledge,
Conversion or decreased IQ
– Lower socioeconomic groups
Disorder – Military personnel exposed to
Epidemiology combat
• Increased Frequency
– Relatives of probands with
conversion disorder
– Monozygotic, but not
dizygotic, twin pairs
 • Cultural norms are important
considerations
• The form of conversion
Conversio may reflect cultural ideas
about acceptable ways to
n Disorder express distress (e.g. falling,
or an alteration of

Epidemiol consciousness)
• Behaviors resembling

ogy conversion or dissociative

symptoms are aspects of
certain culturally sanctioned
religious and healing
ceremonies
 • Common psychiatric conditions:
– Depressive disorders (increased
suicide risk)
– Anxiety disorders (Khan, Nasar et al
2009)
– Somatization disorders
– Conversion in schizophrenia
reported but considered uncommon,
Conversion yet ¼ to ½ admissions to a
psychiatric unit for conversion

Disorder disorder have significant mood

disorder or schizophrenia
•
Comorbidity
Personality Disorders
– 5 to 21% histrionic
– 9 to 40%
passive-aggressive/dependent
– Antisocial
• Medical and especially neurological
disorders occur frequently, with
elaboration of symptoms stemming from
original organic lesion
 Conversion
Disorder
Etiology
• Multidimensional
– Psychoanalytic
Factors
– Learning Theory
– Biological Factors
 • Psychoanalytic Factors
– Repression of unconscious intrapsychic
conflict (instinctual impulse, e.g.
aggression/sexuality, and prohibitions
of expression)
– Conversion of anxiety into a physical
symptom-”the symptom binds anxiety”
– Symptoms allow partial although

Conversion disguised expression of the forbidden

wish or urge, such as to avoid
conscious confrontation with the

Disorder unacceptable impulses

– The conversion disorder symptom has
symbolic relation to the unconscious

Etiology conflict (e.g. vaginismus with sexual

desire, syncope with arousal, paralysis
with anger)
– Symptoms communicate need for
special consideration/treatment
– The individual may derive secondary
gain, with symptoms serving as a
nonverbal means of controlling or
manipulating others
 • Learning Theory
– Conversion disorder
considered as piece of
Conversion classically conditioned
learned behavior
Disorder – Symptoms of illness,

Etiology learned in childhood, are

called forth as a means of
coping with an otherwise
impossible situation.
 • Biological Factors
– Brain imaging
• Hypometabolism of dominant
hemisphere
• Hypermetabolism of
nondominant hemisphere
• ? Impaired hemispheric
communication
Conversion – Corticofugal feedback
• ? Excessive cortical arousal

Disorder setting off negative feedback

loops between the cortex and
reticular formation w/ inhibition
Etiology – Neuropsychological tests
• Subtle cerebral impairments in
verbal communication, memory,
vigilance, affective incongruity,
and attention
– Increased incidence with head
trauma/organicity
Conversion • DSM-V limits to those
symptoms that affect a
Disorder voluntary motor or sensory

Diagnosis function (i.e. functional

neurological symptoms)
 • One or more symptoms or deficits
affecting voluntary motor or sensory
function that suggest a neurological
or other general medical condition.
• Psychological factors are judged to
be associated with the symptom or
Conversion deficit because the initiation or
exacerbation of the symptom or

Disorder deficit is preceded by conflicts or

other stressors
•
DSM-IV-
The symptom or deficit is not
intentionally produced or feigned (as
in factitious disorder or malingering).
TR Criteria • 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 behavior or experience
 • The symptom or deficit causes clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning or warrants medical
Conversion •
evaluation.
The symptom or deficit is not limited to

Disorder
pain or sexual dysfunction, does not occur
exclusively during the course of
somatization disorder, and is not better
DSM-IV- accounted for by another mental disorder.
– Specify type of symptom or deficit:

TR Criteria • with motor symptom or deficit

• with sensory symptom or deficit
• with seizures or convulsions
• with mixed presentation
Conversion
Disorder • Most common symptoms
– Paralysis
Clinical – Blindness

Features – Mutism
 • Sensory symptoms
– Anesthesia and paresthesia common,
especially in extremities (although all
sensory modalities can be involved)
– Distribution of the neurological deficit
inconsistent with either central or
peripheral neurological disease (e.g.

Conversion stocking-and-glove anesthesia, and

hemianesthesia beginning precisely
along the midline)

Disorder – Possible involvement of organs of

special sense (deafness, blindness,

Clinical
tunnel vision)
• Unilateral or bilateral
• Intact sensory pathways by

Features 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.)
 • Motor symptoms
– Abnormal movements (gait
disturbance, weakness/paralysis)
– Movements generally worsen with
calling of attention
– Possible gross rhythmical tremors,
chorea, tics, and jerks
Conversion – Astasia-abasia (wildly
ataxic/staggering gait, gross
Disorder irregular/jerky truncal movements,
thrashing/waving of arms-rare falls

Clinical
w/o injury)
– Paralysis/paresis involving one, two,
or all four limbs (w/o
Features conformation to neural pathways)
– Reflexes remain normal
– No fasciculations/muscle atrophy
(except chronic conversion)
– Normal electromyography
 • Seizure symptoms
– Pseudoseizures
• Differentiation from true
seizure difficult by clinical
observation alone
Conversion • 1/3 of those with
Pseudoseizures have
Disorder coexisting epileptic
disorder
Clinical • Tongue biting, urinary
incontinence, and injuries
Features after falling can occur
(although generally absent)
• Pupillary and gag reflexes
retained
• No post seizure increase in
prolactin concentration
Conversion • Associated psychological
symptoms
Disorder – Primary gain

Clinical – Secondary gain

– La belle indifference
Features – Identification
 • Associated psychological
symptoms
– Primary gain
• Internal conflicts remain

Conversion outside awareness

– Secondary gain
Disorder • Tangible advantages and
benefits as a result of
Clinical being sick (excuses
Features from obligations and
difficult situations,
support and assistance
otherwise not
forthcoming, control of
behavior of others)
 • Associated psychological symptoms
– La belle indifference
• Inappropriate cavalier
attitude toward serious
symptoms (lacking in some,
but also in other seriously ill
Conversion medical patients with stoic
attitude-inaccurate

Disorder determinant of conversion

disorder)

Clinical – Identification
• Unconscious modeling of

Features symptoms after someone

considered important to the
patient
• With pathological grief
reaction, bereaved persons
commonly have symptoms
of the deceased
 • No specific standard laboratory
tests
– Absence of tests supports
diagnosis
• Experimental
Conversion psychophysiology
Disorder – Unique sympathetic
nervous system response as
Clinical measured by skin
conductance upon
Features anxiogenic stimulus
– More rapid cortical evoked
potential spikes in
contralateral sensory cortex
upon physical stimuli
Conversion The most important conditions in
Disorder the differential diagnosis are
neurological or other medical
Differential disorders and substance-
induced disorders.
Disorder
 • Concomitant or previous
neurological disorder or a
systemic disease affecting the
Conversion brain reported in 18% to 64%
Disorder of cases of conversion disorder
• 25% to 50% of cases classified
Differential as conversion disorder
eventually receive diagnoses of
Diagnosis neurological or nonpsychiatric
medical disorders
 •  7-11 year follow up of 99 patients: 22 (30%) of 73
available subjects had organic illness accounting for
presenting symptoms initially diagnosed as
conversion (Slater ETO, Glithero E J. Psychosom
Res, 1965;9:9-13).
• 2.5-10 year follow up of 24 patients discharged
form the neuroscience services of a teahing hospital
with diagnosis of conversion:

Conversion
5 (21%) of 24 with diagnosable neurological disease
(Gatfield PD, Guze SB. Dis Nerv Syst,
1962;23:623-31).

Disorders • 6-12 month follow up of 50 patients discharged

from the neurology service of a teaching hospital
with conversion in differential diagnosis: 7 (14%)

Differential found with organic illness and 3 (6%) with

hysterical elaboration of organic pathology (Raskin
M, Talbott JA, Meyerson AT. JAMA,

Diagnosis •
1966;197:530-4).
64 patients with diagnosis of conversion by
psychiatric consultation service followed for an
average of 3.3 years: 8 (13%) with organic illness
(Stefansson JG, Messina JA, Meyerowitz S. Acta
Psychiatr Scand, 1976;53:119-38).

•  
 • Neurological/medical disorders
– Dementia and other degenerative
disorders
– Brain tumors, subdural hematoma
– Basal ganglia disease, myasthenia

Conversion
gravis, multiple sclerosis
– Polymyositis, acquired myopathies
– Optic neuritis
Disorder – Partial vocal cord paralysis
– Acquired myopathies
Differential – Guillain-Barre, Creutzfeldt-Jacob,
periodic paralysis

Diagnosis – AIDS (early neurological

manifestations)
– Systemic lupus erythematous
– Idiopathic and sarcoma-induced
osteomalacia
– Acquired, hereditary, and drug-
induced dystonia's
 • Psychiatric disorders
– Schizophrenia
Hallucinations presenting with
conversion disorder generally

Conversion present w/o other psychotic

symptoms and often involve
more than one sensory modality
Disorder w/ vague or fantastic content.
– Depressive disorders

Differential – Anxiety disorders

Consider high anxiety states

Diagnosis with phobia and panic attack

associated with somatic
complaints (e.g. difficulty
swallowing)
– Dissociative disorders
Dual diagnosis possible
 • Somatization disorder
– Includes possible sensorimotor
symptoms, but chronic coarse
beginning early in life involving
many other organ systems
• Hypochondriasis
Conversion – No actual loss or distortion of
function

Disorder – Chronic somatic complaints, not

limited to neurological symptoms,

Differential
with characteristic attitudes and
beliefs (disease phobia)
• Body dysmorphic disorder
Diagnosis – Imagined or slight defect in
appearance, with no voluntary motor
or sensory dysfunction
• Pain disorder-symptoms limited to pain
(solely psychological)
• Sexual dysfunction-symptoms limited to
sex
 • Malingering and factitious
disorder
Conversion – Symptoms under conscious,
voluntary control
Disorder – History with malingering
Differential usually more inconsistent
and contradictory than with
Diagnosis conversion disorder
– Fraudulent behavior clearly
goal directed with
malingering
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Tunnel vision Visual fields

Profound monocular blindness Swinging flashlight sign

(Marcus Gunn)
Binocular visual fields
Severe bilateral blindness “Wiggle your fingers;
I’m just testing coordination.”
Sudden flash of bright light
“Look at your hand.”
“Touch your index fingers.”
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Aphonia Request a cough

Intractable sneezing Observe

 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Coma Examiner opens eyes
Ocular cephalic maneuver
Syncope Head-up tilt test
 Conversion Disorder
Distinctive Physical Findings

CONDITION TEST
Anesthesia Map dermatomes

Hemianesthesia Check midline

Astasia-abasia Walking, dancing

Paralysis, paresis Hand drop onto face

Hoover test
Check of motor strength
 Initial symptoms resolve within a
few days to < a month

Conversion in 90 to 100% (95% remit

spontaneously, usually by 2 weeks)
Disorder
Course and 75% have no further episodes, with
20-25% recurring within a year
Prognosis during periods of stress

25 to 50% present later with

neurological disorders or
nonpsychiatric medical conditions
affecting the nervous system
 • Predictors of good prognosis
– Sudden onset
– Easily identifiable stressor
– Good premorbid adjustment
Conversion – No comorbid psychiatric or
medical disorders
Disorder – No ongoing litigation
Course and – Short duration
– Short interval between onset
Prognosis and initiation of treatment
– Above average intelligence
– Paralysis, aphonia, blindness
(tremor and seizures-poor
prognosis)
 • Acute cases
– Reassurance/appropriate
rehabilitation
• Resolution usually
Conversion Disorder spontaneous
Management/Treatment
– Psychotherapy
• A relative
contraindication
 • Chronic cases
– Aggressive therapy of
comorbid psychiatric illness

Conversion – Double bind approach to

therapy
Disorder – Pharmacotherapy
• Anxiolytic or
Treatment antidepressant
medications ?
• Amobarbital interview?
– Psychotherapy?
 • Psychotherapy
– Insight-oriented supportive or
behavior therapy
• Relationship with a caring
and confident therapist most
important feature of the
therapy
• Confrontation re symptoms
being imaginary detrimental
Conversion Disorder • Suggestion of focus on
Management/Treatment stress and coping sometimes
helpful for those resistant to
idea of psychotherapy
– Psychodynamic approaches
• Exploring intrapsychic
conflicts, and the symbolism
of conversion symptoms ???
• 300.7Body Dysmorphic Disorder
Somatoform Disorders301.83
Borderline Personality Disorder
Personality Disorders780.59Breathing-Related
Sleep DisorderSleep Disorders, Dyssomnias298.8
Brief Psychotic DisorderPsychotic Disorders307.51
Bulimia NervosaEating Disorders307.45Circadian
Rhythm Sleep DisorderSleep Disorders,
Dyssomnias300.11Conversion Disorder
Somatoform Disorders301.13Cyclothymic Disorder
Mood Disorders297.1Delusional Disorder
Psychotic Disorders301.6Dependent Personality
DisorderPersonality Disorders300.6
Depersonalization DisorderDissociative Disorders
311Depressive Disorder NOSMood Disorders
300.12Dissociative AmnesiaDissociative Disorders
300.15Dissociative Disorder NOS
Dissociative Disorders300.13Dissociative Fugue
Dissociative Disorders300.14
Dissociative Identity Disorder
Dissociative Disorders
Conversion
Disorder
Summation/Questions