Conversion disorder: Medical mystery with psychological underpinnings

The Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) classifies conversion disorder as one of the somatoform disorders characterized by medically unexplained complaints of multiple physical symptoms, such as inability to speak, blindness, paralysis or numbness with underlying psychological issues or conflicts. In spite of the definition, conversion disorder, a rare occurrence, is difficult to diagnose and remains somewhat of a mystery to medical professionals.

Christine T. Finn, M.D., director, Psychiatry Residency Training Program and director of Crises and Consultation Services in the department of psychiatry at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., says, “People don’t have the insight to make the link between a psychological stressor and a physical component.” Thus, individuals typically see their primary care physician to help diagnose the problem.

“We have to rule out other medical or neurological etiology,” says Finn. “We get a full diagnostic work-up with imaging studies particular to the problem or an EMG (electromyography) to assess motor function. We use objective tests and results to rule out organic disease.” While determining a temporal relationship can help clarify a situation, collateral sources, such as family member and friends, may shed light on an accurate diagnosis, she adds.

Finn adds that a comprehensive evaluation also helps to identify possible malingering. “Malingering equals a means to an end,” she says. While conversion disorder is unconscious, malingering underlies a conscious attempt at a secondary gain, such as avoiding work or school or obtaining drugs, she explains.

When a diagnostic evaluation fails to reveal a physical reason for the symptoms, the physician needs to consider a psychological source for the problem and approach the patient with sensitivity, says Finn. “Acknowledge with the patient that the symptoms are real, but not due to stroke, seizure or other medical issues. Otherwise, the patient will feel cornered,” she says. “I go in with curiosity and try to normalize the person’s feelings.”

Judith Markey, Psy.D., who has a private practice in St. Johnsbury, Vermont, thinks of conversion disorder as “the somatic expression of emotional suffering.”

She says, “It’s not unusual to find some trauma in the person’s history. Having a defense mechanism, such as a somatic symptom, can be useful in these cases. It serves a function. The idea is to find a way to manage the trauma while adapting to the environment,” Markey says. “The central tenet from psychoanalytic theory is that the conversion symptom is the adaptation, or the defense mechanism, and it functions as a compromise between the desire to express a feeling or a conflict that is unconscious and the fear of expressing it.”

Although no direct genetic link has been established, the family culture regarding health and wellness may be a risk factor for developing a conversion disorder. “What does a child learn from the parents about how to express pain? Is there a family history of depression, anxiety or somatic issues?” Markey asks. Additional risk factors include comorbidity, other psychopathology, an unstable emotional life and a lower socioeconomic status. Those living in rural areas and with less knowledge about medical or psychological issues may also have a higher risk, she notes.

During her 22 years in practice, Markey has seen fewer than 10 patients with true conversion disorder. “This condition rarely presents in an outpatient setting,” she says. “Outpatient mental health providers are more likely to see somatization disorder.”

Amy Wachholtz, Ph.D., M. Div., assistant professor of psychiatry and director of health psychology at the University of Massachusetts Medical School and health psychologist at the Psychosomatic Medicine Consultation Services at UMass Memorial Medical Center, agrees that conversion disorder is relatively rare and extremely difficult to diagnose, calling it a coping mechanism that causes a bodily system to shut down due to overload. “Generally, it’s a diagnosis of exclusion, which makes it so much more difficult to diagnose. You have to rule out every potential medical issue,” she says. “There isn’t a good set of diagnostic tools, partly because with conversion disorder you specifically need to decide psychologically the factors directly associated with the symptoms.”

A clear and classic example of verifiable conversion disorder is the “killing fields” in Cambodia in which the Khmer Rouge murdered and buried more than a million individuals following the Cambodian Civil War, according to Wachholtz. This severe traumatic experience serves as a link between psychological suffering and physical manifestation. “After individuals have survived, something retriggers the traumatic experience,” she says.

Wachholtz advises psychologists who want to treat this disorder to have a solid understanding of biology and medical physiology. “You have to identify the trauma first. This is a major component in working to understand why a particular body part is affected,” she says. “There should be symptom management from a medical viewpoint and trauma-based psychotherapy, which might include imagery exercises. The patient [with paralysis or arm or leg numbness] should also engage in physical therapy so he or she doesn’t lose use of the limb.”

Willingness on the part of the patient to “buy-in” to the treatment plan is critical. “The clinician needs to help the patient understand there’s a psychological issue affecting him physiologically. Once the patient agrees and understands, she’s reached a breakthrough stage,” says Wachholtz.

For the most part, women appear to be diagnosed with conversion disorder more frequently than their male counterparts, according to Wachholtz. “Men may have conversion disorder, but do they seek treatment? What is culturally acceptable is how the different genders express trauma,” she says.

Changing the term “conversion disorder” to “functional neurological disorder” is currently under consideration by the team charged with updating the DSM. “If they make the change, it will be a less pejorative term,” says Wachholtz. “It would better describe the symptoms that now put the onus on the patient that they have some weakness.”

Wachholtz warns that applying a conversion disorder label could have long-term negative consequences. “It’s a dangerous diagnosis with a lot of power that will follow the person forever. It can have lifelong implications for how the person will be treated in the medical system,” she says. “The person deserves psychological support to help deal with the issues.”