The Mystery Around Conversion Disorder

Conversion disorder is easily misdiagnosed as malingering, a term used by healthcare providers indicating an individual is causing illness intentionally. The looming mystery surrounding conversion disorder causes people to slip through the cracks from receiving adequate care due to its non-organic etiology. So how can something with no known cause result in such significant impairment?

First known as functional neurological symptom disorder (FND), conversion disorder is a psychological disorder defined by symptoms of sensory and motor impairment that significantly affect human function. The symptoms FND causes are inconsistent with other known neurological disorders, as FND has no true basis. Symptoms are unable to be controlled and considered unintentional (Peeling and Muzio, 2022). Usual symptoms of FND include blindness, paralysis, difficulty swallowing, and inability to speak (Ali et al., 2015). Individuals with FND are more likely to have poor coping skills and additional psychological disorders such as depression, anxiety, and personality disorders. Approximately 48% of people with FND have a type of dissociative disorder (Ali et al., 2015). Low socioeconomic status and individuals living in developing/rural areas are also more likely to develop FND.

Figure 1: Prevalence statistics of conversion disorder (Hull, M., & Vieira, K., 2022)

Contributions of FND come from psychological, social and biological factors. Trauma, negative life events, and acute or chronic stressors occur leading up to FND. A large amount of FND cases have been found to have a history of abuse, emotional and/or sexual. Two major hypotheses attempt to explain the etiology of FND: Psychodynamic and Cognitive-behavioral models (Peeling and Muzio, 2022). Psychodynamic models state that emotional conflict is the cause of FND symptoms. The emotional conflict becomes repressed into the mind which is then converted into a symptom. This hypothesis suggests that this is a type of defense tactic against negative feelings that this kind of conflict would create. Cognitive-behavioral models suggest that exposure to traumatic events or negative feelings related to a specific symptom creates a memory in the mind. FND occurs when a memory is triggered by one excessively worrying about a specific symptom. This trigger then passes through a neurological threshold and becomes an actual symptom. Peeling and Muzio (2022) provide a great example illustrating an experience where an individual sees someone having a seizure:

An example would be an individual seeing someone have a seizure in a movie and creating a memory or a representation of this event in their mind. Later, they encounter anxiety, light-headedness, or dizziness, and fear that they may be experiencing symptoms preceding a seizure. They worry about having a seizure, which activates the representation or memory of a previously created seizure. This activated pathway causes them to have a psychogenic non-epileptic seizure.

Figure 2: Guide to diagnosing conversion disorder (Ali et al., 2015)

FND is backed up by little research, often leading to misdiagnosis. Some cases of FND are mistakenly diagnosed as hypochondriasis, factitious disorder, or malingering. However, it is important to rule out these diagnoses before an FND diagnosis is made. Hypochondriasis is an obsessive worry of having one or more serious illnesses. Factitious disorder occurs when a person acts to have an illness but does not have one. Malingering is defined as one intentionally pretending to have symptoms of a disorder to achieve personal or momentary gain. Given FND’s non-organic cause, some healthcare professionals may assume the patient is exaggerating symptoms and diagnoses a disorder discussed above. Al et al. highlight the incidence in FND, stating that approximately 30% of outpatient neurology patients suffer from unexplained neurological symptoms and 20-25% in a hospital setting. Diagnosis of FND is a clinical obstacle among healthcare providers that requires diligent psychological assessment. Diagnostic criteria has been established by the Diagnostic and Statistical Manual of Disorders (2013):

• One or more motor or sensory impairment

• Clinical finding that show inconsistency between symptoms and other known neurological disorders

• Impairments unable to be explained by other medical or mental disorders

• Symptoms cause significant deficit in social, occupational, or other area of function or requires medical examination

Pourkalbassi, Patel, and Espinosa investigated a case report detailing a 41 year-old male with an unknown cause of seizures examining a FND diagnosis (2019). The patient acquired a significant medical history of traumatic injury including intermittent seizures with prolonged paralysis, multiple cardiovascular disorders, and psychological disorders including attention hyperactivity disorder and bipolar disorder. The complaint upon admittance was multiple seizures and left-sided paralysis which resolved in about 3 to 4 days. This patient also has a history of recurrent hospitalizations and had been examined by multiple healthcare providers with no avail to control the patient’s seizures, despite having a epilepsy diagnosis. Upon hospital examination, all neurological assessments and imaging were normal but the motor and strength exam revealed significant weakness. The patient also complained of sensory impairment on the left side of their body and inability to walk due to weakness. Psychological evaluation tested significant for anxiety and hallucinations. The patient described in this case report meets all criteria for FND diagnosis: Left sided motor and sensory impairment with no clinical evidence of cause, findings inconsistent with other known diagnoses despite seeing multiple providers, symptoms causing significant impairment in function (the inability to walk). The patient's history also raises a concern for FND, experiencing a major traumatic event and having a psychological disorder(s).

Figure 3: Differential diagnosis flow chart (Martin, & Schroeder, 2015)

Treatment plans for FND are highly tailored to the individual to rehabilitate back to normal function. Miller, Archer, and Kapoor (2020) recommend for healthcare providers to first educate the patient about FND and the criteria of such a diagnosis, emphasizing that such a diagnosis is not a neurological disease. Common therapy treatments such as physical therapy, counseling, and group/family therapy have been shown to help patients with FND when tailored to the patient’s needs. Psychotherapies including hypnosis and pharmacotherapy are second options if standard therapy fails.

Conversion disorder continues to be a medical mystery accompanied by little research concerning diagnosis criteria and evidence-based treatment options. Extensive evaluation and examination is crucial for a diagnosis and successful prognosis. A detailed subjective history and differential diagnosis testing is key for conversion disorder. It is important that healthcare providers take their time with patient examination, fully looking at all factors contributing to impairment. Research is still warranted concerning effective treatment options for people with conversion disorder.

Bibliographical References

Ali, S., Jabeen, S., Pate, R. J., Shahid, M., Chinala, S., Nathani, M., & Shah, R. (2015). Conversion disorder - mind versus body: A review. Innovations in Clinical Neuroscience, 12(5-6), 27–33. Edition, F. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association, 21(21), 591-643. Miller, L., Archer, R. L., & Kapoor, N. (2020). Conversion disorder: Early diagnosis and personalized therapy plan is the key. Case Reports in Neurological Medicine, 2020, 1967581. https://doi.org/10.1155/2020/1967581 Peeling J.L., Muzio M.R. Conversion disorder. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551567/?report=classic Pourkalbassi, D., Patel, P., & Espinosa, P. S. (2019). Conversion disorder: The brain's way of dealing with psychological conflicts. Case report of a patient with non-epileptic seizures. Cureus, 11(1), e3902. https://doi.org/10.7759/cureus.3902

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