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Conversion Disorder

DEFINITON

In DSM-IV, conversion disorder is the closest remnant of the old concept


of hysteria. Although it was a key component of the classic syndrome of
hysteria, conversion was separated from hysteria in the DSM system
Acute and temporary loss or alteration in motor or sensory functions
that appears to stem from psychological issues (conflict)
Conversion motor symptoms mimic syndromes such as paralysis, ataxia,
dysphagia, or seizure disorder (pseudoseizures), and the sensory ones
mimic neurological deficits such as blindness, deafness, or anesthesia
There also can be disturbances of consciousness (amnesia, fainting
spells
Nonneurological syndromes such as pseudocyesis (false pregnancy) or
psychogenic vomiting have also been placed under the conversion
disorder category
Usually presented with symptoms suggestive of neurological disease
such as muscle weakness, gait disturbance, blindness, aphonia,
deafness, convulsions, or tremors.

COMPARATIVE NOSOLOGY
In DSM-IV, conversion disorder is defined as the presence of one or more
symptoms or deficits affecting voluntary motor or sensory function,
suggesting a neurological or other medical condition; judged to be
associated with psychological conflict or other stressors, not intentionally
produced or feigned; and not fully explained by other medical conditions,
use of substances, or cultural nuances. It should not be a component of
somatization disorder, and should not be considered due to or caused by
another mental disorder

EPIDEMIOLOGY

Less than 1% in the general population, 5-14% among general hospital


medical/surgical referrals to psychiatry consultation services, and 5-25%
in treated psychiatric outpatients
More frequent in females and can be seen in children as young as 7-8
years old. It is rare after the age of 35 years

ETIOLOGY
Personality factors
Some of the traditional features of hysteria included a detached,
unemotional, calmed attitude in front of what appears to be a severe and

turbulent illness, a trait known as la belle indifference. Histrionic


personality is currently the term that summarizes the drama, flair, and
flamboyance and exhibitionism attributed to these patients. However, none
of these is given any relevance for the DSM-IV diagnosis of conversion
disorder
Psychological factors
The behavioral theory attributes conversion disorder to faulty childhood
learning, with the nonadaptive behavioral responses used for secondary
gain and control of interpersonal relationships
The psychoanalytic theory describes symptoms as compromise
formations with primary gain of conflict resolution through partial
expression of the conflict without conscious awareness of its significance
Some have suggested a strong relationship between childhood
traumatization by sexual or physical abuse and a later propensity for
conversion disorder.

TREATMENT
Screening methods for assessing trauma, dissociative experience, and
posttraumatic stress disorder (PTSD) should be helpful in this process. Any
assessment of conversion symptoms must take into account idiosyncratic
cultural or religious beliefs that may require specific culture-bound
interventions for resolution of conflict and symptom amelior- ation
Approach to the patient
Special attention given to history of trauma, sexual and physical abuse,
and family history of conversion symptoms
Physical examination must pay particular attention to ruling out
neurological diseases such as multiple sclerosis and other PNS-CNS
disorders
Routine
laboratory
studies
are
indicated,
as
well
as
electroencephalograms
(to
distinguish
between
epilepsy
and
pseudoseizures) and other special studies (e.g., MRI, X-rays, spinal tap,
etc.) to rule out other possible organic etiologies
Reassurance
Early intervention can forestall potential chronicity and the progression into
a well-entrenched somatization disorder
Hypnotherapy
The oldest treatment used for conversion disorder. However, it seems it was
not predictive of treatment outcome
Psychotherapy

Once chronicity has developed, intensive treatment may use all


treatment modalities, including hospitalization, individual/group therapy,
insight-oriented therapies, behavioral techniques, hypnosis, sodium
amytal interview, physical therapy, biofeedback, relaxation training, and
medication (primarily for comorbid anxiety, depression, or other
somatoform disorders).
Behavioral interventions should focus on improving self-esteem, the
capacity for emotional expression and assertiveness, and the ability to
communicate comfortably with others

Pharmacological treatment
Accompanying comorbid depression, anxiety, and behavior problems may
respond to pharmacologic interventions. The use of hypnotic or narcoleptic
techniques, if these are being considered, must be tentatively offered to
patients whose fear of passivity or loss of control may induce overwhelming
anxiety