Conversion Disorder— Mind versus Body: A Review

Shahid Ali, MD, Shagufta Jabeen, MD, Rebecca J. Pate, MD, Marwah Shahid,
MS, Sandhya Chinala, MD, Milankumar Nathani, MD, and Rida Shah, MD
Author information Copyright and License information PMC Disclaimer
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Abstract

In this article, the authors accentuate the signs and symptoms of

conversion disorder and the significance of clinical judgment and
expertise in order to reach the right diagnosis. The authors review the
literature and provide information on the etiology, prevalence,
diagnostic criteria, and the treatment methods currently employed in the
management of conversion disorder. Of note, the advancements of
neuropsychology and brain imaging have led to emergence of a relatively
sophisticated picture of the neuroscientific psychopathology of complex
mental illnesses, including conversion disorder. The available evidence
suggests new methods with which to test hypotheses about the neural
circuits underlying conversion symptoms. In context of this, the authors
also explore the neurobiological understanding of conversion disorder.

Keywords: Conversion disorder, hysteria, unconscious conflict,

repressed idea, psychoanalytic factors, psychogenic nonepileptic
seizures, conversion anesthesia, therapeutic alliance,
striatothalamocortical circuits
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INTRODUCTION

Conversion disorder, also called functional neurological symptom

disorder,1 is defined as a psychiatric illness in which symptoms and signs
affecting voluntary motor or sensory function cannot be explained by a
neurological or general medical condition.2 Psychological factors, such as
conflicts or stress, are judged to be associated with the deficits.3 The
term conversion disorder was coined by Sigmund Freud, who
hypothesized that the occurrence of certain symptoms not explained by
organic diseases reflect unconscious conflict.3 The word conversion refers
to the substitution of a somatic symptom for a repressed idea.3,4

Common examples of conversion symptoms include blindness, paralysis,

dystonia, psychogenic nonepileptic seizures (PNES), anesthesia,
swallowing difficulties, motor tics, difficulty walking, hallucinations,
anesthesia, and dementia.5 In patients with conversion disorder, these
symptoms are not caused directly by a physiological effect; rather these
symptoms are caused by a psychological conflict. Patients diagnosed
with conversion disorder are not feigning the signs and symptoms.
Despite the lack of a definitive organic diagnosis, the patient’s distress is
very real and the physical symptoms the patient is experiencing cannot
be controlled at will (i.e., the patient is not malingering an illness). As an
example, according to the Medline Medical Dictionary,6 “...a woman who
believes it is not acceptable to have violent feelings may suddenly feel
numbness in her arms after becoming so angry that she wanted to hit
someone. Instead of allowing herself to have violent thoughts about
hitting someone, she experiences the physical symptom of numbness in
her arms.”

Patients who convert their emotional problems into physical symptoms

spend nine times the cost for healthcare as people who do not, and 82
percent of adults with conversion disorder stop working because of their
symptoms.7 The annual bill for conversion disorder in the United States
is $20 billion, not counting absenteeism from work and disability
payments.7 Despite its clinical importance, there has been only marginal
progress in our understanding of conversion disorder relative to many
other neurological and psychiatric disorders.8

In this article, we seek to emphasize the importance of obtaining detailed

histories and performing physical examinations of patients who present
with symptoms often seen in conversion disorder. We also discuss how
to differentiate conversion disorder symptoms from other somatoform
disorders. The article expands on psychiatric care, the role of
neuroimaging studies in diagnosing conversion disorder, and the
importance of therapeutic alliance in order to achieve the best outcome.
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HYSTERIA TO CONVERSION

The notion of hysteria can be traced to the ancient times. In the

gynecological treatises of the Hippocratic corpus (5th and 4th centuries
before the common era [BCE]), Hippocrates, considered the “father of
medicine,” describes an illness in which the uterus dries up and wanders
the body in search of moisture. They called this hysteria. Symptoms
would then be caused by the uterus pressing on other organs. This
theory is the source of the name, which stems from the Greek cognate of
uterus, hystera.9,10 In the 17th century, Rene Descartes postulated mind-
body dualism, in which mind and body are two distinct substances that
cannot exist in unity, as the body is subjected to mechanical laws and the
mind is not.11 This led to the development of a reductionist medical
model with a dualistic outlook influencing management of
symptoms.12 Emerging theories in the 19th century acknowledged the
involvement of the central nervous system (CNS) associated with
hysterical symptoms. Freud’s psychodynamic theory contributed
significantly to the study of hysteria because his account of symptom
generation, in which unconscious conflict and effective motive are
transformed into bodily complaints, paved the way for the idea of
conversion symptoms.13
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ETIOLOGY

Conversion disorder is associated with conflicts or recent stressors, and

its symptoms manifest as a result of unconscious conflict between a
forbidden wish of the patient and his or her conscience. The conversion
symptoms symbolically represent a partial wish fulfillment without the
individual’s full awareness of the unacceptable desire3 (e.g., vaginismus
with sexual desire, syncope with arousal, paralysis with anger).
Conversion disorder has been attributed to both nonbiological and
biological factors (Figure 1).3,14

FIGURE 1
Factors that can contribute to or cause conversion disorder
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SIGNS AND SYMPTOMS

Conversion symptoms typically begin with some stressor, trauma, or
psychological distress that manifests itself as a physical deficit. There is
no underlying physical cause for the symptom(s), and the affected
individual cannot control the symptom(s). Symptoms may vary in
severity and may come and go or be persistently present. Table 1 lists
typical signs and symptoms of conversion disorder.6

TABLE 1
Typical signs and symptoms of conversion disorder6

Signs

 A debilitating illness that begins suddenly

 History of psychological problems that improve when symptoms of physical illness
appear
 Lack of concern that usually appears with a severe physical symptom
Symptoms

 Blindness
 Paralysis
 Swallowing difficulties
 Inability to speak
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EPIDEMIOLOGY

The reported incidence of conversion symptoms varies widely

depending on the population studied. Studies have estimated that 20 to
25 percent of patients in a general hospital setting have individual
symptoms of conversion, and five percent of patients in this setting meet
the criteria for the full disorder.15,16 Medically unexplained neurological
symptoms account for approximately 30 percent of referred neurology
outpatients.17 In a study of 100 randomly selected patients from a
psychiatry clinic, 24 were noted to have unexplained neurological
symptoms.17
Among adults, women diagnosed with conversion disorder outnumber
men by a 2:1 to 10:1 ratio; less educated people and those of lower
socioeconomic status are more likely to develop conversion disorder;
race by itself does not appear to be a factor.7 There is a major difference
between the populations of developing/third world countries compared
to developed countries; in developing countries, the prevalence of
conversion disorder may run as high as 31 percent.7 Figure 2 illustrates
the sociodemographic factors common in conversion disorder.

Figure 2
Sociodemographic factors of conversion disorder 7,17
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DIAGNOSIS

The diagnosis of conversion disorder continues to be a clinical challenge.

A thorough psychiatric history and examination is necessary to explicate
the onset of symptoms, the presence of stressors, and the presence of
comorbid conditions.5 According to a study, 47.7 percent of the subjects
with conversion disorder experienced some type of dissociative
disorder.18 The diagnosis of conversion disorder should be made after
establishing positive clinical findings that are incompatible with organic
disease or are inconsistent across different parts of the
examination19 and after ruling out any medical conditions the symptoms
are mimicing (Table 2).20

TABLE 2
Differential diagnoses of conversion disorder: organic diseases
 Myasthenia gravis (muscle weakness disorder)
 Multiple sclerosis (blindness resulting from optic neuritis)
 Periodic paralysis (muscle weakness)
 Polymyositis (muscle weakness)
 Stroke
 Lupus
 Spinal cord injury
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Diagnostic criteria. According to the Diagnostic and Statistical Manual

of Mental Disorders, Fifth Edition (DSM-5),21 conversion disorder is
characterized by the following:

 One or more symptoms of altered voluntary motor or sensory

function
 Clinical findings that show evidence of incompatibility between the
symptoms and recognized neurological or medical conditions
 Symptoms or deficit that are not better explained by another
medical or mental disorder
  Symptoms or deficit that cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.

Figure 3 provides an illustrative, stepwise guide to assist clinicians in

diagnosing conversion disorder.
FIGURE 3
Step-wise guide for diagnosing conversion disorder
Differential diagnoses. Patients with conversion disorder may present
with blindness, deafness, pseudo seizures, dystonia, paralysis, syncope,
or other neurological symptoms. The presenting symptoms depend on
the cultural milieu, the patient’s degree of medical knowledge (i.e.,
individuals with a high degree of medical knowledge tend to have more
subtle symptoms and deficits that may closely simulate neurological or
other general medical conditions, whereas those with less medical
knowledge may have more implausible symptoms), and the underlying
psychiatric issue(s).5 Table 3 22-32 lists the differentiating features of
conversion disorder symptoms from those of organic disease. The
following paragraphs review several examples of psychiatric disorders
that should be ruled out before a diagnosis of conversion disorder is
made.

TABLE 3
Differentiating features of conversion disorder symptoms22-32

SYMPTOM DISTINGUISHING FEATURES AND PRESENTATION

In conversion disorder, the patient, though complaining of recent onset of
blindness, neither sustains injury while maneuvering around the office nor
Blindness displays any expected bruises or scrapes. The pupillary reflex is present,
thus demonstrating the intactness of the optic nerve, chiasm, tract, lateral
geniculate body, and mesencephalon.
In conversion deafness, the blink reflex to a loud and unexpected sound is
Deafness
present, thus demonstrating the intactness of the brain stem.
Patients with psychogenic nonepileptic seizures generally lack response to
Psychogenic
treatment with antiepileptic drugs or have a paradoxical increase in seizures
nonepileptic
with antiepileptic drug treatment. The negative history of injury or loss of
seizures
control of bladder or bowel during the seizure episode is also significant.
When weights are added to the affected limb, patients with functional
Tremor tremor tend to have greater tremor amplitude, whereas in those with organic
tremor, the tremor amplitude tends to diminish.
Useful distinguishing features include an inverted foot or “clenched fist,”
Dystonia adult onset, a fixed posture that is apparently present during sleep, and the
presence of severe pain.
In conversion paralysis, the patient loses the use of half of his or her body or
Paralysis of a single limb, but the paralysis does not follow anatomical patterns and is
often inconsistent upon repeat examination.
SYMPTOM DISTINGUISHING FEATURES AND PRESENTATION
The conversion patient may report feeling faint or fainting, but no
autonomic changes are identified, such as pallor, and there is no associated
Syncope
injury. In addition, the fainting spells have a “swooning” character to them,
heightening the drama of these events.
Conversion aphonia may be suspected when the patient is asked to cough,
Aphonia for example, during auscultation of the lungs. In contrast with other
aphonias, the cough is normally full and loud.
Conversion anesthesia may occur anywhere, but it is most common on the
extremities. One may see a typical “glove and stocking” distribution;
Anesthesia however, unlike the “glove and stocking” distribution that may occur in a
polyneuropathy, the areas of conversion anesthesia have a very precise and
sharp boundary, often located at a joint.
In conversion paraplegia, one finds normal, rather than increased, deep
Paraplegia tendon reflexes, and the Babinski sign is absent. In doubtful cases, the issue
may be resolved by demonstrating normal motor evoked potentials.
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Hypochondriasis. Hypochondriasis is the excessive preoccupancy or

worry about having one (or more) serious physical illnesses. This
debilitating condition is the result of an inaccurate perception of the
condition of body or mind despite the absence of an actual medical
condition (e.g., “I know I’ve got cancer; they just haven’t done the right
test yet”).33

Factitious disorder. Factitious disorder is a condition in which a person

acts as if he or she has a physical or mental illness when he or she is not
really sick. Factitious disorder by proxy is when a person acts as if a
person in his or her care has an illness when the person does not.
Factitious disorder is considered a mental illness because it is associated
with severe emotional difficulties. People with factitious disorder
deliberately create or exaggerate symptoms of an illness in several ways.
They may lie about or fake symptoms, hurt themselves to bring on
symptoms, or alter tests (such as contaminating a urine sample) to make
it look like they or the person in their care is sick. Those with factitious
disorder have an inner need to be seen as ill or injured without the need
to achieve personal or financial gain.34
Somatisation. Somatisation is a condition in which a person experiences
physical symptoms that are inconsistent with or cannot be fully
explained by any underlying general medical or neurological condition.
Preoccupation with these symptoms leads to excessive distress in the
patient.35

Malingering. Malingering is not a mental disorder; however, psychiatrists

and neurologists will likely encounter an individual malingering a
psychiatric or neurological illness at some point in their careers.
Malingering is defined as intentionally feigning the symptoms of a
physical, psychiatric, or neurological disorder in order to achieve
personal or financial gain. The individual is fully aware that he or she is
feigning the symptoms and has clear knowledge of why he or she is
doing it (e.g., for financial gain, recognition, or revenge).10
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NEURAL CORRELATES OF CONVERSION DISORDER

The growing trend to measure structural and functional changes in the

brain through imaging has contributed significantly to improving
understanding of the neural mechanisms of many psychiatric conditions,
including conversion disorder.13 Functional imaging findings suggest the
involvement of prefrontal cortex as a candidate region in conversion
disorder.32,36-39

Marshall et al36 performed positron emission tomography (PET) on a

woman with chronic left-sided paralysis (without sensory loss) in whom
no organic lesion could be found. Regional cerebral blood flow was
measured when she tried to move either her paralyzed leg or her other
leg. The attempt to move the paralyzed leg failed to activate the right
primary cortex. Instead there was activation of the right orbitofrontal
and right anterior cingulate gyrus. The authors hypothesized that
inhibitory pathways involving the orbitofrontal cortex and anterior
cingulate may “disconnect” the premotor areas from the primary motor
cortex, preventing the patient’s conscious intention from being
translated into action. The authors suggested that the activation seen
when this patient was preparing to move her affected limb provides
evidence against feigning. The case report also suggests that inhibition of
willed movement may play an important role in people with functional
paralysis.36

Vuilleumier et al32 proposed another hypothesis in which it is argued that

patients who exhibit symptoms of conversion disorder have a deficit in
volition that involves the left dorsolateral prefrontal cortex (DLPFC) and
striatothalamocortical circuits. This explanation implicates different
structures and functions in seeking to explain the cause(s) of conversion
disorder. It is possible, given the complexity of brain structure and
function, that conversation disorder is associated with deficits in both
planning and execution (premotor stage).

By beginning to understand the neural mechanisms of conversion

disorder we may gain valuable insights into the cognitive processes
involved in attention and volition and reduce some of the controversy
and stigma associated with this common disorder.
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TREATMENT

Presenting the diagnosis. Once conversion disorder is confirmed, the

key to successful treatment is the establishment of a strong therapeutic
alliance with the patient and the incorporation of a goal-oriented
treatment program. Many patients who experience conversion disorder
are unable to understand the inner conflict, which is perhaps occurring
on an unconscious level.5 Confronting patients about the “psychological
nature” of their symptoms can and usually does make the symptoms
worse.3 However, patients can only achieve resolution of the conflict and
the physical symptoms once they are able to recognize the
connection.5 Table 4 lists examples of how to present the diagnosis to
patients.
TABLE 4
Effective presentation of the diagnosis17,19,41
Because patients with conversion disorder may be less open to psychological explanations than
patients with defined neurological illness, the groundwork for a discussion of psychological
and stress-related factors must be approached carefully.

 Do no inform the patient of the diagnosis on the first encounter.

 Reassure the patient that the symptoms are very real despite the lack of a definitive
organic disease.
 Avoid giving the patient the impression that you feel there is nothing wrong with him
or her.
 Provide socially acceptable examples of diseases that often are deemed stress-related
(e.g., pepticular disease, hypertension).
 Provide common examples of producing symptoms (e.g., queasy stomach when talking
in front of an audience, heart racing with asking someone for a date).
 Provide examples of how the subconscious influences behavior (e.g., nail biting,
pacing, foot tapping)
 Emphasize that the symptoms are potentially reversible (unlike many neurological
diseases). Patients can be told that although their bodies are not functioning properly,
improvement is possible because there is no structural damage.
 Explain that understanding and accepting the diagnosis often leads to improvement
because it allows proper engagement with rehabilitation rather than being stuck
wondering or worrying about what is wrong.
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Psychotherapy. The cornerstone of treatment for conversion disorder is

psychotherapy aimed at elucidating the emotional bases of
symptoms.40 Psychotherapy can include individual or group therapy,
behavioral therapy, hypnosis, biofeedback, and relaxation training.
Cognitive behavioral therapy (CBT) has shown the highest efficacy in
treatment of pseudoseizures.22 Behavioral interventions should focus on
improving self-esteem, increasing the capacity to express emotions, and
improving the ability to communicate comfortably with others.22

Physical therapy. Research has shown that physical therapy can be an

effective method of treatment.41 Physiotherapy treatment is essential in
the management of people with conversion disorder to allow them to
overcome their physical symptoms and prevent secondary
complications, such as muscle weakness and stiffness, that may occur as
a result of inactivity.41 Progressive exercises that start as simple tasks
and move to more challenging ones has shown to be effective in those
with neurological disorders as well as conversion disorder. The physical
therapist seeks to build the patient’s motor skills by gradually providing
less verbal and tactile cueing or other assistance while the patient
performs certain tasks.41

Medication. Conversion disorder can also be improved through the use

of medications to treat underlying psychiatric issues, such as depression
and anxiety. Medications may include antidepressants, anxiolytics, or
others depending on the psychiatric co-morbidity.40 Regular follow-up
appointments with a neurologist and/or psychiatrist should be provided
to the patient to limit emergency room visits and unnecessary diagnostic
or invasive tests.40

Prognosis. A good prognosis can be expected in patients where

conversion disorder had a sudden onset, a short duration, an early
identifiable stressor, no ongoing litigation, good premorbid functioning,
and lack of comorbid psychiatric disorders.3
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CONCLUSION

Conversion disorder is a condition where mental or emotional crises

produce stress that converts to a physical problem. People diagnosed
with conversion disorder are not feigning the symptoms; the symptoms
are real. Therefore, it is important not to label patients with conversion
disorder as manipulative. The signs and symptoms of conversion
disorder can be difficult to tease out of a multitude of other possible
diagnoses, and a thorough understanding of each patient’s pathology
should be the first step in establishing the correct diagnosis and effective
treatment. It is very important to efficiently and effectively obtain
medical and psychiatric history from the patient while being careful
about how and when to ask about psychological symptoms. Creating a
therapeutic alliance with the patient is essential to a successful
outcome.5 A thorough psychiatric examination is necessary to explicate
the onset of symptoms and presence of stressors and comorbid
conditions. This would help establish an integrated overall
understanding of how abnormal psychological states can convert to a
neurological deficit in the absence of somatic pathology. Focusing
research on neural correlates of conversion disorder has immense
potential for therapy and prevention. In terms of treatment, there is no
single method that can be globally recommended. Regular follow-up
visits combined with cognitive-behavioral therapy and physiotherapy
(for motor symptoms) have shown promising results. Pharmacotherapy
may be necessary for any underlying psychiatric disorders.
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Footnotes

FUNDING:No funding was provided for the preparation of this article.

FINANCIAL DISCLOSURES:The authors have no conflicts of interest relevant to the

content of this article.
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