CONVERSION DISORDER
FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER
Introduction
During times of serious stress, everyone occasionally experiences mild dissociative or
somatic symptoms. But when concern about these symptoms is severe and leads to
significant distress or impairment, a somatic symptom disorder may be diagnosed.
In the past, somatic symptom disorders (formerly known as somatoform disorders)
were included with the various anxiety disorders (and neurotic depression) and
considered to be forms of neurosis. This was because anxiety was thought to be the
underlying cause of all neuroses whether or not the anxiety was experienced overtly.
Functional Neurological Symptom disorder, also known as conversion disorder, lies
within the diagnostic category of somatic symptom and related disorders. The term
conversion disorder is relatively recent. Historically this disorder was one of several
disorders that were grouped together under the term hysteria. It is characterized by the
presence of neurological symptoms in the absence of a neurological diagnosis (see
Feinstein, 2011). In other words, patients are present with one or more symptoms or
deficits affecting voluntary motor and sensory functioning that strongly suggest a
medical or neurological condition. However, the pattern of symptoms or deficits is not
consistent with any neurological disease or medical problem. Some of the examples are
partial paralysis, blindness, deafness, and episodes of limb shaking accompanied by
impairment or loss of consciousness that resemble seizures.
Even though the diagnosis can only be made after a full medical and neurological
workup has been conducted. It is also important to emphasize that the person is not
intentionally producing or faking the symptoms. Psychological factors are often judged
to play an important role because symptoms usually either start or are exacerbated by
preceding emotional or interpersonal conflicts or stressors.
Early observations dating back to Freud suggested that most people with conversion
disorder showed very little of the anxiety and fear that would be expected in a person
with a paralyzed arm or loss of sight. This seeming lack of concern was known as la belle
indifférence—French for “the beautiful indifference.” For a long time it was thought to
be an important diagnostic criterion for conversion disorder. However, la belle
indifférence occurs only in about 20 percent of patients. Lack of concern about
symptoms or their implications is also not specific to conversion disorder. For these
reasons, this phenomenon has become de-emphasized in more recent editions of the
DSM (Stone et al., 2006, 2011).
Symptoms
Categories of Symptoms:
1. Sensory Symptoms or Deficits :
Can involve any sensory modality (e.g., vision, hearing, touch).
Common sensory deficits:
•Visual: Blindness (can navigate without bumping into objects).
•Auditory: Deafness (can respond to hearing their name).
•Anesthesias: Loss of feeling in areas like the hands (e.g., glove anesthesia).
Symptoms often don’t align with anatomical pathways, suggesting sensory input is
registered but not consciously recognized.
2. Motor Symptoms or Deficits :
Range of motor dysfunctions, such as:
•Paralysis: Often affects a single limb; selective loss of function (e.g., can’t write but can
scratch).
•Aphonia: Can only whisper but coughs normally.
•Globus: Sensation of a lump in the throat.
Functional abilities can return under certain circumstances (e.g., emergency situations).
3. Seizures :
Conversion seizures resemble epileptic seizures but:
•No EEG abnormalities.
•No post-seizure confusion or memory loss.
•More exaggerated movements and lack of injury.
4. Mixed Presentation :
A combination of sensory, motor, and seizure-like symptoms.
Diagnosis Issues:
•Symptoms often don’t match known physical mechanisms.
•The input (e.g., sight, sound) is registered but not consciously perceived.
Clinical Picture of FNSD
DSM-5 Criteria of Conversion Disorder
Prevalence and demographic characteristics :
Conversion disorders are found in approximately 5 percent of people referred for
treatment at neurology clinics. The prevalence in the general population is unknown,
but even the highest estimates have been around only 0.005 percent (APA, 2013).
Conversion disorder occurs two to three times more often in women than in men (APA,
2013). It can develop at any age but most commonly occurs between early adolescence
and early adulthood (Maldonado & Spiegel, 2001). It generally has a rapid onset after a
significant stressor and often resolves within 2 weeks if the stressor is removed,
although it commonly recurs (Merkler et al., 2015).
Important issues in diagnosing conversion disorder :
Symptoms in conversion disorder can stimulate a variety of medical conditions; an
accurate diagnosis can be extremely difficult. Even though the rate of misdiagnosis has
vastly reduced (i.e., from nearly 30 percent in the 1950s to 4 percent in the 1990s).
Several other criteria are also commonly used for distinguishing between conversion
disorders and true neurological disturbances:
● The frequent failure of the dysfunction to conform clearly to the symptoms of the
particular disease or disorder simulated. For example, little or no wasting away
or atrophy of a “paralyzed” limb occurs in conversion paralysis, except in rare and
long-standing cases.
● The nature of the dysfunction is highly selective. In conversion blindness, the
affected individual does not usually bump into people or objects, and “paralyzed”
muscles can be used for some activities but not others.
● Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms
can usually be removed, shifted, or re-induced at the suggestion of the therapist.
Similarly, a person abruptly awakened from sound sleep may suddenly be able to
use a “paralyzed” limb.
Diagnostic accuracy :
In 1965, an influential follow-up study reported that 33% of patients diagnosed with
hysteria about 10 years earlier subsequently received a different diagnosis that could
explain their initial symptoms.Data such as these, when replicated, contributed to the
demise of hysteria as a diagnostic category. However, follow-up studies done after 1970
have, on average, reported a significantly lower rate of misdiagnosis of conversion
symptoms, namely in the order of 0.4%–4%. This difference may be explained by
improvements in the quality of the follow-up studies and, to a lesser extent, the
advances made in neuroimaging techniques.
Prognosis :
Various reports on the prognosis of patients with CD are available. Some report
hospitalization for weeks, and others months and yet others on spontaneous recovery
within 2 weeks, without any treatment intervention. It should be stated, however, that
the longer the time to recovery, the less complete will be the recovery.17 Reports have
shown that between 15% and 75% of CD patients demonstrate organic signs within 5
years of diagnosis due to failure to recover or recurrence.
Associated features of conversion disorder :
Conversion disorder, or functional neurological symptom disorder, is often
accompanied by several associated features. One notable characteristic is la belle
indifférence, where patients show a surprising lack of concern about their significant
symptoms, such as paralysis or blindness. Additionally, the symptoms may provide
secondary gain, offering unconscious psychological benefits like avoiding stressful
situations or receiving attention. The disorder is frequently triggered by a preceding
emotional or psychological stressor, even if the patient is unaware of the connection.
Symptoms are typically inconsistent with medical or neurological findings, and the
patient may also experience co-occurring conditions like anxiety or depression.
Causal Factors of Conversion Disorder
Symptoms of functional neurologic disorder may appear suddenly after a stressful
event, or with emotional or physical trauma. Other triggers may include changes or
disruptions in how the brain functions at the structural, cellular or metabolic level. But
the trigger for symptoms can't always be identified. Some basic causes of the conversion
disorder are as:
● A history of childhood abuse.
● Having other mental health conditions, especially depression or anxiety.
● A recent stressful or traumatic event.
● A recent health condition or event acting as a trigger for conversion disorder.
Psychological Factors :
● Psychodynamic Theory:
Conversion disorders are thought to develop as a result of stress or internal
conflicts of some kind. Freud used the term conversion hysteria for these
disorders (which were fairly common in his practice) because he believed that the
symptoms were an expression of repressed sexual energy—that is, the
unconscious conflict that a person felt about his or her repressed sexual desires.
However, in Freud’s view, the repressed anxiety threatens to become conscious,
so it is unconsciously converted into a bodily disturbance, thereby allowing the
person to avoid having to deal with the conflict. This is not done consciously, of
course, and the person is not aware of the origin or meaning of the physical
symptom. Freud’s theory that conversion symptoms are caused by the conversion
of sexual conflicts or other psychological problems into physical symptoms is no
longer accepted outside psychodynamic circles.
Sociocultural Factors :
● Stressful life events:
The important role often attributed to stressful life events in precipitating the
onset of conversion disorder, it is unfortunate that little is actually known about
the exact nature and timing of these psychological stress factors (Roelofs et al.,
2005). One study compared the frequency of stressful life events in the recent
past in patients with conversion disorder and depressed controls and did not find
a difference in frequency between them.However, the greater the negative impact
of the preceding life events, the greater the severity of the conversion disorder
symptoms (Roelofs et al., 2005).
● Cultural expectancy :
The physical symptoms can be seen as providing negative reinforcement (relief or
removal of an aversive stimulus) because being incapacitated in some way may
enable the individual to escape or avoid an intolerably stressful situation without
having to take responsibility for doing so. In addition, they may provide positive
reinforcement in the form of care, concern, and attention from others. It is the
case that, in some cultures, expressing intense emotions is not socially
acceptable. When viewed through a sociocultural lens, a diagnosis of conversion
disorder can therefore be seen as a more socially sanctioned way of expressing
distress and escaping an unpleasant situation. However, although becoming sick
or disabled is more socially acceptable, it is important to keep in mind that the
person is not deliberately choosing to lose his or her sight or become unable to
walk. Instead, unconscious processes are thought to be at work.
Biological Factors :
● Neurological factors
Dysfunction in Brain Networks :
Conversion disorder presents with neurological symptoms that have no
detectable organic cause, such as paralysis, blindness, or non-epileptic seizures.
While the symptoms appear similar to those seen in well-known neurological
disorders, medical tests often reveal no structural abnormalities. Research into
conversion disorder suggests that these symptoms arise due to dysfunction in
specific brain networks involved in motor control, sensory perception, and
emotional regulation.
● Genetic
Twins study :
Monozygotic twins are conceived when a single egg fertilized by a single sperm
splits into two after fertilization. Such twins have nearly 100% of their genes in
common. Both of them invariably have the same blood type and are of the same
sex. Dizygotic twins are conceived when two eggs are fertilized by two different
sperms. They can simply be thought of as siblings who are born at the same time.
They share an average of 50% of their genes, and their blood types and sex can be
either same or different.
Therefore, through further research, it was found that identical twins are similar
in many psychological characteristics to fraternal twins. It is believed that the
monozygotic twins would even have almost similar personality traits considering
the above factors.
Twin studies, which can provide much more conclusive evidence of genetic
influences on a disorder, also suggest a moderate genetic contribution to
conversion disorder. Monozygotic co-twins of a twin with the disorder are about
twice as likely to develop the disorder as are dizygotic co-twins, with about 31 to
42 percent of the variance in liability due to genetic influences (Sullivan, Neale, &
Kendler, 2000). The estimate is substantially higher (70 to 80 percent) for more
severe, early-onset, or recurrent depressions.
First Degree Relatives :
The results from family and twin studies make a strong case for a moderate
genetic contribution to the causal patterns of disorder.
Treatment
Treatment begins with presentation of the diagnosis. Even before a formal discussion of
treatment options, the diagnostic workup and the presentation of the diagnosis offer
opportunities to improve the patient’s outcome.
Many physicians are uncomfortable presenting a diagnosis of conversion disorder to a
patient. Angry reactions from patients may derive from a perceived sense (sometimes
based on reality) of abandonment by a physician. A prior experience of abandonment or
abuse by authority figures compounds these reactions. Therefore, careful attention to
how the diagnosis is presented can often help maintain an ongoing therapeutic
relationship.
We also find it useful to give printed educational materials on conversion disorder to
patients and their families. Because patients with conversion disorder may be less open
to psychological explanations than are patients with defined neurological illness, the
groundwork for a discussion of psychological and stress related factors must be laid
carefully.
● We begin by summarizing the test results, noting that brain waves were normal
during the episode. Instead of labeling seizures as “real” or “unreal,” we
emphasize that the symptoms are genuine and affect the patient’s life, even if
they're not epileptic. We reassure patients that we understand they aren’t faking
or intentionally causing their episodes, and that not having epilepsy is positive
news. While we don't know the exact cause of nonepileptic seizures, they typically
result from interactions between the subconscious mind and the body.
● We explain that many patients with conversion disorder have a history of trauma
or stress during key developmental years and often pride themselves on being
emotionally "strong," leading them to overlook emotional responses when facing
challenges. Though the trauma may have occurred long ago, physical symptoms
typically arise later, triggered by new, often subtle events. Patients with
conversion disorder are usually competent, caring individuals who focus more on
others than themselves. Those who recognize these traits in themselves may find
it easier to accept the diagnosis and the need for psychological treatment.
Treatment Options :
For treating patients with conversion disorder, we propose a treatment approach
that considers risk factors, perpetuating factors, and triggers. First, the treatment
team should assess relevant risk factors for each patient. If the patient has
cognitive impairment or communication difficulties, the focus should be on
simple behavioral interventions, physical therapy, reassurance, and helping them
express distress. In cases where family dynamics or sociocultural factors are
significant, especially with children and adolescents, family therapy may be
necessary to address underlying issues.
Treating comorbid psychiatric conditions is crucial for symptom resolution and,
in some cases, addressing the comorbid condition alongside the conversion
disorder diagnosis may be enough. However, if symptoms persist, psychological
treatments targeting perpetuating factors are needed. Patients’ and physicians’
responses to the symptoms can unintentionally reinforce them, with behaviors
like avoidance or suppressing distress reinforcing an external locus of control.
Cognitive behavioral therapy is well-suited to address these issues.
● Cognitive Behavioural Therapy :
Cognitive behavior therapy for nonepileptic seizures is based on the
concept that symptoms occur when a patient is confronted with
“intolerable or fearful circumstances” and that such symptoms are
maintained by a “vicious circle of behavioral, cognitive, affective,
physiological, and social factors”. Specific techniques include graded
exposure to feared or avoided situations, use of problem solving
techniques, and the reframing of distorted cognitive beliefs about their
illness and powerlessness. An open trial of cognitive behavior therapy
decreased the frequency of nonepileptic seizures and improved
psychosocial functioning.
● Pharmacotherapy :
Given the lack of data for controlled trials on the pharmacological
treatment of conversion disorder, the current practice is to use
medications appropriate for the comorbid psychiatric and somatic
symptoms and to withdraw antiepileptic drugs unless they are benefiting
the comorbid conditions. Anecdotal studies report improvement with
selective serotonin reuptake inhibitors (SSRIs), beta blockers, analgesics,
and benzodiazepines. An open trial of antidepressants in patients with
psychogenic movement disorder and recent or current depression also
showed that class of medications to be effective in reducing conversion
symptoms.
● Psychotherapy :
The primary focus of this therapy is on the role of trauma and dissociation,
inadequate attachment, and the patient’s difficulty in coping with
intrapsychic conflict and anxiety. Group therapy, preferably in conjunction
with concurrent individual therapy, offers advantages of reinforcing
psychoeducational concepts, while providing the opportunity for patients
to learn from and help each other.
Conclusion
“Conversion disorder” is the term used in the DSM-IV classification system, originating
from the description by Breuer and Freud of pseudoneurological symptoms resulting
from conversion of an unconscious psychological conflict to somatic representation
Early recognition of conversion disorder can reduce unnecessary tests and medications.
Effective long-term treatment requires a comprehensive approach, addressing risk
factors, comorbid conditions, and cognitive patterns that sustain symptoms. The
doctor-patient relationship plays a key role in outcomes. Difficult-to-treat patients may
evoke feelings of frustration or mistrust, which, if unaddressed, can harm the
relationship and lead to overuse of medications and procedures.
There is limited research on prospective studies or controlled trials for treating
nonepileptic seizures, but current evidence supports a multidisciplinary approach.
Interventions like cognitive behavioral therapy for restructuring thoughts and
psychodynamic therapy for addressing trauma and dissociation are recommended.
Case studies
Questions from Previous Year Papers
Q. Discuss the psychoanalytic explanation for conversion disorder (5 M).
(Understanding and Dealing With Psychological Disorders, 2017)
Q. Write a short note on Conversion Disorder (7.5 M).
(Abnormal Psychology, 2013)
Q. Write a short note on Causes of Conversion Reaction (7.5 M).
(Abnormal Psychology, 2015)
Q. With the help of a case-study, discuss the causal factors of conversion reaction (15M).
(Abnormal Psychology, 2017)
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