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New Treatments for Conversion Disorder

Conversion disorders are characterized by symptoms or deficits affecting voluntary motor or sensory function that suggest yet are not fully explained by a neurological or other general medical condition or the direct effects of a substance. Diagnosis is not made if the presentation is explained as a culturally sanctioned behavior or experience, such as bizarre behaviors resembling a seizure during a religious ceremony. Symptoms are not intentionally produced or feigned, that is, the person does not consciously contrive a symptom for external rewards, as in malingering, or for the intrapsychic rewards of assuming the sick role.

Four subtypes with specific examples of symptoms are defined: with motor symptom or deficit (e.g., impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, and urinary retention); with sensory symptom or deficit (e.g., loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations); with seizures or convulsions; and with mixed presentation (i.e., has symptoms of more than one of the other subtypes).

Epidemiology

Vastly different estimates of the incidence and prevalence of conversion disorder have been reported. Much of this difference may be attributable to methodological differences from study to study, including the changing definition of conversion disorder, ascertainment procedures, and populations studied.

Conversion symptoms themselves may be common; it was reported that 25% of normal postpartum and medically ill women had a history of conversion symptoms at some time during their life, yet in some instances, there may have been no resulting clinically significant distress or impairment. Lifetime prevalence rates of treated conversion.

Etiology and Pathophysiology

The term conversion implies etiology because it is derived from a hypothesized mechanism of converting psychological conflicts into somatic symptoms, often symbolically (e.g., repressed rage is converted into paralysis of an arm that could be used to strike). A number of psychological factors have been promoted as part of such an etiological process, but evidence for their essential involvement is scanty at best.

Diagnosis and Differential Diagnosis

The first consideration is whether the conversion symptoms are explained on the basis of a general medical condition. Because conversion symptoms by definition affect voluntary motor or sensory function (thus pseudoneurological), neurological conditions are usually suggested, but other general medical conditions may be implicated as well. Neurologists are generally first consulted by primary care physicians for conversion symptoms; psychiatrists become involved only after neurological or general medical conditions have been reasonably excluded. Nonetheless, psychiatrists should have a

Apparent conversion symptoms mandate a thorough evaluation for possible underlying physical explanation. This evaluation must include a thorough medical history; physical (especially neurological) examination; and radiographical, blood, urine, and other tests as clinically indicated. Reliance should not be placed on determination of whether

Symptoms of many neurological illnesses may appear inconsistent with known neurophysiological or neuropathological processes, suggesting conversion and posing diagnostic problems. These illnesses include multiple sclerosis, in which blindness due to optic neuritis may initially present with normal fundi; myasthenia gravis, periodic paralysis, myoglobinuric myopathy, polymyositis, and other acquired myopathies, in  

Course, Natural History, and Prognosis

Age at onset is typically from late childhood to early adulthood. Onset is rare before the age of 10 years and after 35 years, but cases with an onset as late as the ninth decade have been reported. The likelihood of a neurological or other medical condition is increased when the age at onset is in middle or late life. Development is generally acute, but symptoms may develop gradually as well. The course of individual

Factors associated with good prognosis include acute onset, clearly identifiable precipitants, a short interval between onset and institution of treatment, and good intelligence. Conversion blindness, aphonia, and paralysis are associated with 

Treatment

Reports of the treatment of conversion disorder date from those of Charcot, which generally involved symptom removal by suggestion or hypnosis. Breuer and Freud, using such psychoanalytic techniques as free association and abreaction of repressed affects, had more ambitious objectives in their treatment of Anna O., including the 

Therapeutic approaches vary according to whether the conversion symptom is acute or chronic. Whichever the case, direct confrontation is not recommended. Such a communication may cause a patient to feel even more isolated. An undiscovered physical illness may also underlie the presentation.

In acute cases, the most frequent initial aim is removal of the symptom. The pressure behind accomplishing this depends on the distress and disability associated with the 

If symptoms do not resolve with such conservative approaches, a number of other techniques for symptom resolution may be instituted. It does appear that prompt resolution of conversion symptoms is important because the duration of conversion symptoms is associated with a greater risk of recurrence and chronic disability. The other techniques include narcoanalysis (e.g., amobarbital interview), hypnosis, and behavioral therapy. In narcoanalysis, amobarbital or another sedative-hypnotic medication such as lorazepam is given intravenously to the point of drowsiness. Sometimes this is followed by administration of a stimulant medication, such as methamphetamine. The patient is then encouraged to discuss stressors and conflicts. This technique may be effective acutely, leading to at least temporary symptom relief as well as expansion of the information known about the patient. This technique has not been shown to be especially effective with more chronic conversion symptoms. In

Anecdotally, somatic treatments including phenothiazines, lithium, and electroconvulsive therapy have been reported effective. However, in many cases, this may be attributable to simple suggestion. In other cases, resolution of another psychiatric disorder, such as a psychotic disorder or a mood disorder, may have led to the symptom's removal. It should be evident from the preceding discussion that in acute conversion disorders, it may be not the particular technique but the influence of suggestion that is specifically associated with symptom relief. It is likely that in various rituals, such as exorcism and other religious ceremonies, immediate "cures" are based on suggestion. Suggestion seems to play a major role in the resolution of "mass

Longer term approaches to the treatment of conversion disorder include strategies previously discussed for somatization disorder--a pragmatic, conservative approach involving support and exploration of various conflict areas, particularly of interpersonal relationships. A certain degree of insight may be attained, at least in terms of