CONVERSION DISORDER

Conversion disorder is characterized by the occurrence of certain signs or symptoms that are clearly inconsistent with what is known about anatomy and pathophysiology. For example, the patient may complain of blindness, yet cortical visual evoked potentials are normal. Or a patient may complain of complete anaesthesia of the left upper extremity and go on to describe the boundary of the anaesthesia as being a clear-cut line encircling the elbow. Other common complaints include hemiplegia, deafness, and seizures. There is no unified model for Conversion Disorder and its conceptualization relies on psychological, social, and biological factors. The onset of the symptoms is sudden, and often preceded by either psychological or physical trauma.

Symptoms

The symptoms of conversion disorder vary from person to person. These symptoms also vary in severity. The symptoms may occur one time or repeat when the stressor is recalled. These symptoms may include;

1. Tremors, possibly with limited consciousness
2. Paralysis, usually in an arm or leg
3. Balance issues
4. Weakness or numbness in arms or legs
5. Vision problems, such as blindness or double vision
6. Swallowing difficulty, which may come from feeling like there’s a lump in your throat
7. Slurred speech or an inability to speak 
8. Partial or total hearing loss

The symptoms of conversion disorder usually start abruptly at the time of a stressful or traumatic event. Most of the time the symptoms will also stop abruptly. 

Diagnosis

The diagnosis of conversion disorder comes from meeting certain criteria given by the Diagnostic and Statistical Manual of Mental Disorders. Some of these criteria include but are not limited to;

1. Symptoms of movement in your body or sensory symptoms that can’t be controlled
2. Symptoms that happen after or in relation to a stressful event or emotional trauma
3. Symptoms that cannot be explained medically or physically
4. Symptoms that negatively affect your daily life.

There aren’t specific tests that diagnose conversion disorder. The tests that are performed are primarily to rule out any medical conditions that may be causing your symptoms. The types of tests your doctor may perform during diagnosis depend on the type of symptoms you’re having. Some tests include but are not limited to;

1. CT scan, X-rays, or other imaging to rule out possible injuries and neurological conditions
2. Electroencephalogram for seizures symptoms to rule out neurological causes
3. Routine tests such as checking your blood pressure and reflexes

Causes

The exact causes of conversion disorders are unknown. Theories regarding what happens in the brain to result in symptoms are complex and involve multiple mechanisms that may differ, depending on the type of conversion disorder. Basically, parts of the brain that control the functioning of your muscles and senses may be involved, even though no disease or abnormality exists. Symptoms of conversion disorder may appear suddenly after a stressful event, or with emotional or physical trauma. Other triggers may include changes or disruptions in how the brain functions at the structural, cellular, or metabolic level. But the trigger of symptoms cannot always be identified.

Risk Factors

Factors that may increase your risk of conversion disorder include;

1. Having a neurological disease or disorder, such as epilepsy, migraines, or a movement disorder
2. Recent significant stress or emotion or physical trauma
3. Having a mental health condition, such as a mood or anxiety disorder, dissociative disorder, or certain personality disorders
4. Having a family member with a functional neurologic disorder
5. Possibly, having a history of physical or sexual abuse or neglect in childhood

N/B: The names of the patients have been initialized for confidentiality purposes.

Case 1

UN is a 7-year-old boy and the third of the parents five children of his parents. The father is a politician and a businessman while the mother though well-educated with university education is employed. The family environment is characterized by occasional disharmony that the children often witness. UN was well until one day when he developed fever, headache, and vomiting. His Father gave him sulfadoxine/pyrimethamine (Fansidar) and paracetamol that was bought from a pharmacy shop. The fever and other symptoms subsided by the next day but UN started exhibiting unusual body movements. He could no longer stand erect and walked in a staggering gait, with the legs crossing themselves while walking. Despite the abnormal gait, UN did not fall and was apparently unconcerned about his problem. He was reviewed by a paediatric neurologist who noted the inconsistency between UN’s normal neurological examination finding and his symptoms. Conversion disorder was suspected, and UN was referred for psychiatric evaluation. During the psychiatric review, he was observed to cling to the father, apparently unconcerned with the goings-on around him, playing with the father’s phone without any observable difficulties. Both parents were extremely anxious about UN’s problems especially as his elder sister had in the past experienced turning of neck and tongue protrusion following ingestion of medicine to control vomiting when she had malaria, which UN witnesses. While being reviewed, UN made no efforts to move his limbs when he was asked to do so and slumps when efforts were made to keep him in a standing position. He could, however, run to give the father his phone when it rang without any difficulties. An assessment of Conversion Disorder was made. The parents were given psychoeducation and we were encouraged to avoid reinforcing the behavior. UN resumed school the next day and has remained stable.

Treatment Modalities

• Psychological treatments

The traditional approaches to the treatment of this disorder were hypnosis and psychoanalysis. Such approaches, however, have not been validated and their success has been limited. Cognitive Behavioral Therapy (CBT) that is aimed at changing the maladaptive thinking patterns about pseudoneurological symptoms have shown to be effective in some studies, but due to small sample sizes and heterogeneity of symptom presentation, replication is necessary to bolster claims about effectiveness. The success of all these treatments relies on the assumption that a psychological stressor linked to conversion exists and can be brought into the patient’s awareness where it can be resolved, or that maladaptive thoughts related to the symptoms can be challenged. However, patients with Conversion Disorder are often unaware of the psychological stressors that may have caused their symptoms, and in some cases, there may not be a clear stressor in the first place.

Furthermore, these patients are often reluctant to acknowledge the psychological underpinnings of their symptoms and may be resistant to treatments that they construe as inappropriate and discordant with their belief of a physical basis for their symptoms. Hence, an approach that genuinely acknowledges the debilitating nature of the symptoms but also educates the patients more generally about stress management and body-mind interrelationships in a manner that respects defenses, rather than directly challenges them, may be appropriate. The rehabilitation approach is another method aimed at working with rather than against conversion symptoms. 

• Rehabilitation approach

Evidence emerging from clinical cases suggests that a structured and active rehabilitation approach may be particularly effective for patients with motor conversion symptoms. These treatments are similar to those received by patients with symptoms arising from organic pathology and focus on maximizing physical function in rehabilitation settings.

• The treatment should be geared towards the presenting symptoms and the patient should be referred to the rehabilitation setting appropriate for their physical symptoms 
• This approach accomplishes several goals. First, it acknowledges that presenting symptoms are not under the patient’s dysfunction as real. Secondly, this approach is concordant with the patient’s beliefs about the physical basis for their problem. Together these factors provide the patient with a non-threatening and supportive context for relinquishing the symptoms of conversion
• Adopting an approach where remaining in treatment is contingent on patient’s improvement appears to motivate patients and minimizes manipulative behavior, thereby reducing negative interactions with rehabilitation staff. Treating the problem as physical rather than emphasizing psychological causation may help “save safe” and minimize the stigma associated with a psychiatric condition. However, given that a large number of patients with conversion disorder present with other psychiatric conditions as well as social problems that can impact treatment, an interdisciplinary approach to management may be needed.

NOTE

• Symptoms of conversion disorder are not feigned but may represent a bodily manifestation of emotional distress.
• Psychological, sociocultural, and biological factors may be involved in conversion disorder, suggesting the need for a multidisciplinary approach to formulation and treatment.
• A non-confrontational approach that emphasizes psychoeducation of the mind-body relationship and validates the patient’s suffering rather than minimizing symptoms may help build the alliance.
• Treatment aimed at maximizing physical function in rehabilitation settings appears to be promising
• Treating the underlying psychological conflict may be challenging but beneficial in patients with identified emotional distress
• More treatment studies are needed in identifying effective clinical management.