Uncovering Conversion Disorder: A Guide for Primary Care Physicians

Case Study

A 42-year-old man presented to a neurology clinic after having consulted multiple neurologists over many years. His complaint was of left leg weakness, buckling at the knee, and the sensation that his leg, which dragged behind him, “did not belong to him.”

All previous studies (MRI of the brain and whole spine, neurophysiology, and orthopedic examination of the knee) were normal. A previous neurologist had told him that he had functional weakness of his leg, but he remained convinced that something had been missed on the tests.

Upon examination, the patient displayed obvious left-sided Hoover sign as well as a hip abductor sign (ie, weakness of hip abduction in the affected limb, which returned to normal with contralateral hip abduction). His dragging, monoplegic gait was typical of functional paralysis.

This case, presented by Stone and Edwards depicts a typical presentation of conversion disorder (CD), a mystifying condition that involves a series of motor symptoms such as paralysis, tremor, pain, and gait disorder for which no medical basis is found.¹ Unlike factitious disorder or malingering, symptoms are not generated to intentionally deceive others or receive some secondary gain, such as disability benefits. Instead, the symptoms are “physical manifestations of emotional distress that are not under conscious awareness or control.”²

The term “conversion disorder” has been renamed as “functional neurological symptom disorder (FNSD)” in the current Diagnostic and Statistical Manual (DSM-5).³ Diagnostic criteria are listed in Table 1.

A recent article by Tsui and colleagues reviews the “complex” neurological and pain-related presentation of CD, as well as the diagnostic process and suggested management. The authors note that the somatic symptoms associated with the disorder can be extremely “debilitating” and that their treatment can be “difficult, protracted, and costly.” Focus on specific symptoms (eg, weakness, paralysis, psychogenic nonepileptic seizures or pain) can obfuscate research and diagnosis. In patients who present with pain, the problem is compounded because of the subjectivity of the experience of pain, and the absence of diagnostic tests.²

Assessing CD and distinguishing it from other conditions can be challenging. It can be particularly difficult for primary care providers (PCPs) to distinguish CD from neurological disorders.

To shed light on diagnosis and management of CD in the primary care setting, MPR interviewed Patricia Tsui, PhD, Clinical Psychologist, Department of Anesthesiology, Chronic Pain Division, Stony Brook University, Stony Brook, NY.

MPR

What challenges might a PCP face in diagnosing CD?

Dr Tsui

Functional neurological disorders present as medical symptoms, such as paralysis, some type of altered motor or sensory function, weakness, paralyzed limbs, pain, or pseudo seizures. It can be tricky to distinguish these from actual neurological disorders.

MPR

What are the components of the workup a patient should receive in the primary care setting?

Dr Tsui

The PCP should take a detailed history, including symptoms in all organ systems, pain, fatigue, sleep disturbances, memory, and concentration problems. It is also important to note that these patients often have a history of depression, anxiety, and panic attacks, as well as other somatic disturbances, such as headaches, sleep difficulties, fibromyalgia, chronic pain, irritable bowel syndrome, and multiple chemical sensitivities.

A thorough physical examination and neuroimaging and laboratory studies to investigate specific complaints are also necessary. Routine laboratory tests, CT scan and MRI of the brain or spine should be performed at the first visit. Other neuroimaging studies may also be neccessary. It is important to bear in mind that certain autoimmune-related neurological diseases as well as amyotrophic lateral sclerosis (ALS) may also be normal, so a neurology follow-up and ongoing monitoring of symptoms may be advisable.

MPR

When should a PCP refer a patient to a specialist?

Dr Tsui

In my experience, PCPs are usually good at noticing when symptoms might be somatoform in nature and identify them as medically unexplained, e.g. when physical examination and imaging results do not match up with reported or displayed symptoms. If a PCP suspects that the cause of a patient’s symptoms may have a non-organic basis, administering the 15-item Patient Health Questionnaire (PHQ-15) can be very helpful. It is a quick screening tool that can be used in a primary care environment.

MPR

In what way is the PHQ-15 useful?

Dr Tsui

Patients are asked to rate how often their physical symptoms are bothersome. These symptoms include a wide range of symptoms, including fatigue, dyspeptic complaints, stomach and back pain, pain in the joints or limbs, sleeping difficulties, headaches, chest pain, bowel complaints, menstrual pain or problems, dizziness, shortness of breath, palpitations, pain or problems during sexual intercourse, and fainting. A cutoff of 10 has been found to have significant accuracy in suggesting somatoform disorder. If a patient scores high on the PHQ-15, and the exam suggests symptoms that do not quite match up, then the PCP can refer the patient to a specialist.

MPR

How might the PCP discuss the possibility of a CD diagnosis with the patient?

Dr Tsui

Communicating this diagnosis can be tricky and must be done with sensitivity. Patients often think there is an underlying medical pathology that is yet to be uncovered and may get upset and go elsewhere to get another opinion. As a consequence, some people with these symptoms end up going to multiple specialists. So how the diagnosis is communicated is essential. It is especially important to note that one has to be certain all treatable medical conditions are ruled out. If they are not, then I would support seeing other specialists in search of appropriate diagnosis and treatment.

It begins with building rapport and developing a trusting therapeutic relationship with the patient. It is also necessary to take time to adequately explain and educate the patient about the condition.

Explain the findings and how they do not match up with the symptoms. The provider can say, “You have been to so many specialists who also have not found a cause for your symptoms. What do you make of this?” Asking open-ended questions allows patients to come to their own conclusions.

The PCP should communicate and emphasize that the symptoms are not “all in the head,” and acknowledge that they are very distressful. The provider can say, “the brain is complex and the way we process information is complicated. Since all the bases have been covered, in terms of finding a physiological cause for your symptoms, it might be helpful to consider other approaches. So let’s try physical therapy to get you functioning again, and consider seeing a mental health specialist, not necessarily to receive medications, but to discuss your experience and figure out the best course of action.”

It is important to find the patient’s source of motivation because that will contribute to the treatment plan, and the patient will understand that the physician shares the same goals, such as returning to work, participating in family life, or becoming independent. Working toward a common goal and moving in a stepwise fashion can lead to improvements and once people start seeing improvements, the motivation builds on itself.

MPR

What approaches have been found helpful for CD?

Dr Tsui

There is strong evidence⁴ to support multidisciplinary inpatient treatment with a team that consists of rehabilitation specialists and psychologists. There is also some support for CBT and hypnotherapy as interventions.

Case Study

The neurologist demonstrated to the patient that when he was distracted by moving his right leg, strength returned to his left leg. He explained, “Your brain is having trouble sending a message to your leg to make it move, but when you are distracted, the message can get through. This test shows me there is a problem with the function of your nervous system, not damage to it.”

The patient had already noticed that distraction improved his symptoms and was receptive to the diagnosis. The patient and physician discussed the role of using distraction techniques during walking, and the physician provided further self-help information for functional neurologic symptoms.⁵

At a follow-up visit, the patient stated that “understanding the physical basis of the diagnosis had made a big difference to him.” He now had confidence that “it was the correct diagnosis and further tests would not be helpful.” Now that he knew the diagnosis, he “felt less anxious about it, paid less attention to it, and as a consequence seemed to experience it much less.”

Table 1

DSM-5 Diagnostic Criteria for Functional Neurological Symptom Disorder (Conversion Disorder) 

One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom or deficit is not better explained by another medical or mental disorder. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth ed. Arlington: American Psychiatric Association; 2013.

Table 2

Symptoms, Presentation, and Distinguishing Features of CD

Symptom	Presentation and Distinguishing Features
Blindness	Sudden onset No injury sustained while maneuvering around the office No bruises/scrapes Pupillary reflex present
Deafness	Blink reflex to loud unexpected sound present
Psychogenic nonepileptic seizures	Lack response or paradoxical increase in seizures with antiepileptic drug treatment Negative history of injury or loss of bladder/bowel control during seizure episode
Tremor	When weights are added to the affected limb, greater tremor amplitude vs diminished tremor amplitude in those with organic tremor
Dystonia	Inverted foot or “clenched fist” Adult onset Fixed posture apparently present during sleep Severe pain
Paralysis	Loss of use of half of the body or of a single limb Paralysis does not follow anatomical patterns Paralysis often inconsistent upon repeat examination
Syncope	Patient may report feeling faint or syncope, but no autonomic changes identified (eg, pallor) No associated injury Fainting spells have “swooning” character
Aphonia	Normal/full cough during auscultation of the lungs
Anesthesia	Most common in extremities “Glove and stocking” distribution common Unlike “glove and stocking” distribution that may occur in polyneuropathy, areas of conversion anesthesia have precise, sharp boundary, often located at a joint
Paraplegia	Normal rather than increased deep tendon reflexes Absence of Babinski sign Normal motor evoked potentials

This article originally appeared on MPR