Conversion Disorder (Functional Neurological Symptom Disorder) DSM-5 300.11 (ICD-10-CM Multiple Codes)
DSM-5 Category: Somatic Symptom and Related Disorders
Introduction
Conversion disorder is a somatic disorder characterized by a persistent change in motor or sensory function. Specific symptoms vary and can include weakness, paralysis, trouble with swallowing, unusual speech, numbness, unusual sensory problems, or a mixture of symptoms. Some patients experience an acute version of conversion disorder that lasts only a few days or less. For some, symptoms can persist for weeks or months. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), conversion disorder is most common after a stressful life event or period of stress and is two to three times more common in women than men (American Psychiatric Association, 2013).
Symptoms of Conversion Disorder
The DSM-5 explains that the primary symptom of conversion disorder is unusual or impaired motor or sensory function with no medial or neurological cause. The symptoms are not faked or made up by the patient. Conversion disorder can occur in both adults and children. Symptoms can be manifested in a variety of ways. Some patients experience muscle weakness, numbness or paralysis in one area of the whole body. Other patients experience abnormal movement, such as tremors, involuntary movements, seizures or trouble walking. Conversion disorder can also present as an inability or impairment in swallowing or difficulty speaking. In some cases, patient experience specific sensory disturbances such as problems seeing or hearing. In many cases, the patient experiences a combination of these symptoms. In severe cases, the patient may appear to be in a coma with no medical cause (American Psychiatric Association, 2013).
The DSM-5 is clear that although they are not required for diagnosis, patients often experience dissociative symptoms that begin around the onset of the episode. Often, patients behave as though they are not concerned about the physical symptoms they are experiencing, even when they are severe and debilitating. Most attacks occur during a period of stress or after a stressful life event, although this is not always the case. The DSM-5 further explains that many patients who present with conversion disorder often have physical conditions unrelated to the current symptoms, and often have mental health issues such as anxiety or depression. Many patients have a history of childhood sexual abuse (American Psychiatric Association, 2013).
Comorbidity
Conversion disorder is commonly diagnosed in people who already experience anxiety disorders, panic disorder, depression or personality disorders. The patient may already have a history of different somatic disorders. Substance use and psychosis are commonly not associated with conversion disorder (American Psychiatric Association, 2013). Several clinical studies examining conversion disorder has found that symptoms occur in women who have been treated for eating disorders (Goldstein, Peters & Madden, 2013)
Cultural Considerations
When diagnosing conversion disorder, the DSM-5 warns that symptoms that can be explained by culturally sanctioned experiences or behaviors cannot be considered. The DSM-5 makes this distinction because several cultures acknowledge syndromes or health conditions that are very similar to conversion disorder. The prevalence of conversion disorder varies widely by culture. In Turkey, for example, the prevalence rate is estimated to be higher than 5%. In Italy, however, the rate is less than three tenths of a percent. Interestingly, the primary symptom of the disorder also varies by culture. Turkish patients are most likely to experience loss of consciousness. In Japan, however, nearly 40% of patients diagnosed with conversion disorder present with blindness or other visual disturbance. Nearly a quarter of patients experience paralysis. A Dutch study found that motor symptoms are most common among their conversion disorder patients. In Nigeria, patients diagnosed with conversion disorder almost always complain of sensory sensations, particularly the feeling of something crawling on their skin, or unexplained heat on their skin.. Patients in India, Nepal and Pakistan most commonly feel heat on the inside of their bodies (Brown & Lewis-Fernandez, 2011).
The reason for cultural differences in symptoms is unclear, although several possibilities have been considered. One hypothesis is that the differences are related to the unique diagnostic practices and healthcare options available in specific countries or regions. Symptoms may also reflect the current health concerns of the particular culture. Patients across cultures tend to experience onset of conversion disorder after or during a stressful experience. This factor also varies by culture. 89% of American patients report a stressful event, but only 31% of Japanese patients report any current stressor. This is likely caused by cultural views of stress and openness to discussing stress (Brown & Lewis-Fernandez, 2011).
Treatment for Conversion Disorder
Although there is no standard protocol for treating conversion disorder, most experts agree that a multidisciplinary approach is necessary. Successful interventions involve cooperation among psychiatrists, clinical psychologists, and rehabilitation medicine specialists (Allam, 2013). Because comorbidity is high, it is important that the patient’s existing physical or psychological continue to be treated, or be addressed if not previously treated. Before being referred for psychological treatment, patients have typically undergone numerous tests and visited a multitude of doctors to relieve physical symptoms. Therefore, patients often resent psychiatric services and may not be forthcoming about existing psychological stress or disturbances. Still, mental health care is necessary to overcome conversion disorder (Rosebush & Mazurek, 2011)
Both psychodynamic and cognitive behavior therapy is helpful in overcoming conversion disorder. Cognitive behavioral therapy works to identify and change thoughts that may be leading to physical symptoms. During psychoanalysis, the therapist works with the patient to indentify unconscious traumas, life events and internal conflicts that may be causing psychological distress. Psychoanalysis is believed to be successful in treating 70% of conversion syndrome diagnoses (Rosebush & Mazurek, 2011).
Although often controversial, hypnosis is also successful in treating conversion disorder. In many cases, symptoms seem to be relieved during the hypnosis session. For example, a parallelized limb will move, or a tremor will cease. Post-hypnotic suggestion is then used to maintain improvement. One study found that 80% of patients treated with hypnosis recovered from their symptoms and were still symptom-free six months after treatment (Rosebush & Mazurek, 2011).
Conclusion
Conversion disorder is a somatic disorder during which patients experience physical or neurological symptoms that cannot be explained by any injury, illness or other medical condition. Although it is not required for diagnosis, most patients diagnosed with conversion disorder have experience trauma, injury or psychological disturbance. Symptoms and prevalence depend greatly on the cultural background of the patient. Therefore, cultural sensitivity is an important component of diagnosis and treatment. Although no consensus exists regarding a specific treatment for conversion disorder, psychodynamic therapy and hypnosis tend to be most successful. Patients benefit from care that involves both psychiatric and physical care.
References
Allam, C. Conversion motor disorder. A case report. Anals of Physical and Rehabilitation Medicine. 56(1): 121
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Brown, R.J. & Lewis-Fernandez, R. (2011). Culture and conversion disorder: implications for DSM-5. Psychiatry. 74(3): 187-206
Goldstein, M., Peters, L. & Madden, S. (2013). The use of effective treatments: The case of an adolescent girl with anorexia nervosa in the context of a conversion disorder. Clinical Child Psychology and Psychiatry.18(2): 214-223
Rosebush, R. & Mazurek, M.F. (2011) Treatment of conversion disorder in the 21st century: Have we moved beyond the couch? Current Treatment Options in Neurology. 13(3): 255- 266
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