Conversion Disorder

What is Conversion Disorder

Conversion Disorder or CD is a neurological condition that is often triggered by stressful situations such as after acute trauma or a prolonged period of stress and high tension. CD is psychological in nature and cannot be explained by testing, imaging, or bodily injury. According to a study in the American Journal of Psychiatry, 89% of patients diagnosed with CD have a comorbidity of another psychiatric illness. 47% of the patients in this study had a preexisiting diagnosis of dissociative disorder too. Also, overlapped was patient self reports of emotional/physical/sexual childhood abuse, self harm, or suicide. Its physical manifestation can affect the nervous system and somaticize to often look like TBI, SCI, or CVA type diagnosis.

Population Most Affected

Conversion Disorder is most common among women, regardless of pediatric or adult populations. It has also been seen to be comorbid within people with previously existing mental conditions, PTSD, veterans, ex-military, mood disorders, major depression, personality disorders, and dissociative identity disorder. The first symptoms often show up in adolescence and young adulthood.

Pediatrics and Conversion Disorder

A study done in the Indian Journal of Pediatrics quotes two researchers Maisami and Freeman stating that “conversion reactions in children are a form of body language, which represents the child’s plea for help in situations where the child is unable to cope”. This study followed sixteen children, mostly girls. Their causes go psychological distress were school, mother and child abuse, financial stress, family conflict, and sibling/friend conflict. Also, this study hypothesized another reason being a lack of attention at home. The psychological distress manifests as physical symptoms that are paid more attention to and therefore encouraged by the family.

Pediatric Research

In 1988 a study conducted at the Royal Alexandra Hospital for Children in Australia, followed 52 children with CD in a 10 year case study. Of the cohort, 75% were admitted around late summer and spring during school exams and beginning of the new school year. There were no kids below 5 years old and most were girls. 12/52 kids had multiple readmissions, and the mode age was 10-12 years old. Out of all the children, a few had pre-existing seizure disorders, dwarfism, DM, and cataracts. Some had a history of sexual and physical abuse in the home, divorced parents, open conflict in the home, anxious and high pressure/expectation home environments, and family loss.

Out of the 52 kids, 3 kids suffered blindness, 36 had gait disturbances, some had full paralysis, 77% had pain with resultant paresthesia, and 8 kids had seizures. About 8 cases were very difficult with slow progress and months of treatment. 4 cases never resolved with multiple symptoms and organ failure at the time of discharge. Out of those 4, 2 cases spontaneously resolved when returned to a different and less stressful home situation.

Common Symptoms
  • Paralysis of part of the body or the whole body
  • Jerky movements
  • Loss of senses; smell/vision
  • Loss of voice
  • Seizures
  • Hallucinations
  • Gait Disturbances
  • Paresthesias
  • Pseudoseizures

Criteria to rule in symptoms: 1 or more neurological dysfunctions, no other explanations or physical findings, symptoms so severe that they require medical necessity (via NIH)

Diagnosis

Doctors start ruling out any physical or anatomical reasons for your symptoms and presentation. They will run neurological testing, physical tests, and may ask a series of questions about daily stress and/or mental strain in your life. This can come from life at work, school, home, or recent/prolonged trauma and events.

Treatment

Patients are often sent to PT/OT to regain physical function. A systematic review by Fitzgerald showed that there is a high effectiveness of physiotherapy in resolving symptoms of gait disturbances secondary to a diagnosis of conversion disorder. Ideally, they are being treated for the underlying cause of psychosis. Treatment can include counseling and psychotherapy, CBT, hypnosis, and any sort of SSRI/tricyclics or PTSD interventions for the time being.

How PT is Effective For Treating Conversion Disorder

A study done by Kaur found that the longer a patient is not treated due to a late diagnosis of CD, or other reasons, the patient can develop secondary muscle weakness, loss of motor skills, and muscle contractures. This can lead to physical impairments in all ADL’s and work/school activities. Kaur’s study states PT can help improve strength, independence, confidence, mobility, anxiety, posture, and stiffness. Other interventions include introduction into weight bearing activities, gait training, ambulation, relaxation, endurance, activity tolerance, and patient specific things.

Another study done by the British Rheumatology Journal states that a patients plan of care should focus on re-teaching them old skills they have lost but still need. This study also suggests to start slow and within the patients capabilities to gain rapport. In the case of a child, give them a chart to track their progress. This can be how long they tolerate an activity or their ambulation distance.

A medical student from The Royal College of Surgeons in Ireland created an informational guide to treating CD with physical therapy. The guide states PT can help patients regain sensation by continuously stimulating the dermatomes. This study breaks down rehabilitation for CD into 5 main parts.

      1. Establishing rapport. Patient education, patience, and support.
      2. Pre-gait activities. Weight shift, transfers, bed mobility, coordination, and stretching.
      3. Supported gait activities. Standing, parallel bar gait training, side step, backward step, and balance.
      4. General mobility. Gait outside parallel bars, obstacle involvement (cones), endurance to activity, less or no use of AD, multi-tasking (walking and talking).
      5. Community re-integration. Back to school or work tasks, community ambulation in different settings, and discharge planning.
Prognosis

Generally not life threatening, but loss of physical function and traumatic mental state of mind can cause lasting effects and decline in function overall if you do not seek treatment. It can last several weeks if the patient is being treated. A study published in PubMed showed 1/4 patients may have a recurrence with or without developments of new symptoms. The patient as risk for CD may suffer long with the diagnosis due to not seeking treatment, not addressing underlying psychological causes, a comorbidity of serious psychiatric disorders, symptoms that are slow to present and slow to resolve, and motor control impairments (seizures and tremors) not explained by epilepsy. One study published in the Journal of Psychomatic Research showed that out of 40 children followed for 4 years (after their initial diagnosis), 36 of them had a complete recovery. The remaining 4 had some or no improvement with treatment.

 

References