Conversion Disorders

Question 1

What are conversion disorders?

Answer 1

• When patients present with motor and/or sensory dysfunction not explained by known physical disorders or pathophysiological mechanisms
• No organic cause

Question 2

What are the characteristics of conversion disorders?

Answer 2

• Occurs most often at 10 -35yo
  - Usually lasts a few weeks or months
  - Many have medical problems as well
  - 20-50% of people diagnosed with a functional disorder are eventually found to have a physical cause for their symptoms

Question 3

What are the risk factors of conversion disorders?

Answer 3

• Having a family member with the disorder 
• Having been sexually abused as a child
• Having a very stressful home or work life 
• Being a woman
• Belonging to a lower socioeconomic class

Question 4

What is the DSM-IV diagnostic criteria?

Answer 4

• One or more symptoms/deficits present that affect voluntary motor/sensory function that suggest a neurological or other general medical condition
•  Psychological factors are judged to be associated
• Cannot be explained fully by a general medical condition, direct effects of a substance, or as a culturally sanctioned behaviour/experience.
• Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
•  Not limited to pain or sexual dysfunction, & is not better accounted for by another mental disorder

Question 5

What is the presentation of conversion disorders?

Answer 5

• Weakness/paralysis of a limb or the entire body
•  Impaired hearing or vision
•  Loss/disturbance of sensation
•  Impairment or loss of speech
•  Psuedoseizures
•  Fixed dystonia
•  Tremor, myoclonus or other movement disorders 
• Gait problems
•  Syncope

Question 6

What is the presentation of weakness in conversion disorders?

Answer 6

• Involves whole movements rather than muscle groups
• Simultaneous contraction of agonists & antagonists during testing
• Discontinuous resistance during testing or give-way weakness may exist
• Muscle wasting is absent
• Reflexes are normal
• Level of weakness may not be consistent with level of function

Question 7

What is the presentation of sensory symptoms in conversion disorders?

Answer 7

• Sensory loss is inconsistent when tested on more than one occasion & is incompatible with peripheral nerve or root distribution.
• Discrete patches of anesthesia or hemisensory loss that stop in the midline may be present

Question 8

What is the presentation of visual symptoms in conversion disorders?

Answer 8

• Includes monocular diplopia, triplopia, field defects, tunnel vision, & bilateral blindness associated with intact pupillary reflexes.
• Nystagmus may be observed in patients with apparent blindness when exposed to a rotating striped drum

Question 9

What is the presentation of motor performance in conversion disorders?

Answer 9

• Inability to stand despite normal ability to move legs when lying down or sitting OR inability to move legs in lying or sitting, but able to stand up
• Jerky, exaggerated movements
• Unexplained/inconsistent tremor
• Bizarre gait patterns with unusual co-ordination yet
  no falls
• May use affected side spontaneously without realising it

Question 10

What are the rehab approaches for conversion disorders?

Answer 10

• Behavioural management
•  Psychotherapeutic approach
• Physical therapy approach

Question 11

What should physiotherapy treatment be based on?

Answer 11

• Long & short term goals should encourage rapid achievement of normal activities
•  Collaboration with family members 
• Using positive suggestion

Question 12

What does physio management often involve?

Answer 12

• Training usual tasks (e.g. standing up, standing balance, walking)
• Giving patients permission to relinquish their symptoms

Question 13

How should progress be measured in conversion disorders?

Answer 13

• Avoid prolonged documentation of outcome measures

-  Use outcome measures judiciously to demonstrate improvement and normal performance

Question 14

What are the factors associated with favourable prognosis?

Answer 14

• Sudden onset
  - Presence of stress during onset
  - Short interval between diagnosis and
  treatment
  - High level of intelligence
  - Absence of psychiatric disorder
  - Aphonia and blindness as presentation

Question 15

What are the factors associated with poor prognosis?

Answer 15

• Presentation with severe disability of long duration
•  Over 40 years of age
•  Convulsions & paralysis as presentation

Question 16

What is the acronym for managing conversion disorders?

Answer 16

• Confrontation is avoided
• Organic disease is ruled out
• No progress until mastery of previous stage
• Vulnerability requires “face saving” options
• Establish concrete goals/progress measures
•  Reinforce gains through positive feedback
•  Stress management techniques
•  Ignore disability
•  Open communication with team & family
•  Need consistent team of care providers