Chapter 37. Conversion Disorder

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José R. Maldonado: Chapter 37. Conversion Disorder, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition.

Edited by Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI:

10.1176/appi.books.9781585622986.260013. Printed 5/10/2009 from www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VII. Somatoform and Factitious Disorders >

Chapter 37. Conversion Disorder

INTRODUCTION

DSM-IV-TR (American Psychiatric Association 2000) has six criteria for the diagnosis of conversion

disorder. The essential diagnostic feature is “one or more symptoms or deficits affecting voluntary

motor or sensory function that suggest a neurological or other general medical condition” (criterion

A, p. 498). Although this criterion was used in DSM-I (American Psychiatric Association 1952) and

DSM-II (American Psychiatric Association 1968), it was broadened in DSM-III (American

Psychiatric Association 1980) to encompass symptoms involving “a loss of or alteration in physical

functioning that suggests a physical disorder” (p. 244). Criterion B establishes that “psychological

factors are judged to be associated with” (p. 498) the initiation and maintenance of symptoms or

deficits. Criterion C was added to rule out the intentional (feigned) production of symptoms, as in

factitious disorder or malingering. Criterion D establishes that the symptom or deficit cannot, after

appropriate investigation, be fully explained by a neurological or other general medical condition or

by the direct effects of a substance. It also establishes that culturally sanctioned behaviors or

experiences (e.g., possession syndrome) may not be diagnosed as a conversion disorder. Criterion E

establishes that the symptoms must have clinical significance as evidenced by the presence of

significant distress, social or occupational impairment, or the need to pursue medical evaluation

and treatment. Finally, criterion F notes that the symptom or deficit “is not limited to pain or sexual

dysfunction, does not occur exclusively during the course of somatization disorder, and is not better

accounted for by another mental disorder” (p. 498).

Early in the history of psychiatry, the most common conversion symptoms reported included

paralysis, somnambulism, convulsive attacks, psychogenic blindness, and mutism (Janet 1925).

Now we know that conversion disorder may mimic many other neurological and medical disorders.

DSM-IV (American Psychiatric Association 1994) and DSM-IV-TR recognize four clinical subtypes

based on the nature of the presenting symptoms. These are motor symptoms or deficits, sensory

symptoms or deficits, seizures (i.e., pseudoseizures or “nonconvulsive” seizures), and mixed

presentations, which combine any of the aforementioned presentations. As in the past, somatoform

disorders seem to be more common in women. Recent studies suggest that the large majority

(78%) of conversion disorder patients and nearly all (95%) of the somatization disorder patients

were women (Tomasson et al. 1991).

In the acute setting of the emergency department (ED), patients with conversion disorder usually

present with neurological symptoms and invariably undergo multiple diagnostic tests. In a study of

42 consecutive ED presentations, Dula and DeNaples (1995) found that 21 (50%) of the patients

were diagnosed in the ED, and of those patients, 10 were released home from the ED. Most clinical

symptoms mimicked neurological disorder (e.g., weakness, pain, seizure-like activity, loss of

consciousness). Thirty patients (71%) received laboratory studies in the ED, and 2 others were

admitted for further evaluation. As discussed earlier, psychiatric comorbidities were common.

Twelve (29%) patients had previous histories of psychiatric disorders, 4 (10%) had histories of

alcohol and drug abuse, 2 (5%) had prior conversion reactions, 3 (7%) had chronic illnesses, and 4

(10%) had been victims of previous head trauma.

Conversion disorder often presents in association with medical conditions and other psychiatric

disorders (Bowman 1993). Preceding or coexisting neurological disorders have been reported in

44%–70% of conversion disorder patients (Barsky 1989; Krumholz and Niedermeyer 1983).

Hysterical symptoms are common in neurological practice, accounting for about 1% of casesPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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presenting to the neurology clinic (Marsden 1986). The most common psychiatric diagnoses are

major depressive disorder and dissociative disorders, both of which have been found in about 85%

of acute conversion cases (Bowman 1993; Roy 1980; Ziegler et al. 1960). Among the anxiety

disorders, posttraumatic stress disorder and panic attacks appear most common, occurring in a

reported 33% and 11% of conversion cases, respectively (Bowman 1993). Personality disorders

are not uncommon in patients with conversion disorder, with histrionic and dependent personality

disorders or traits being most common in women and antisocial personality disorder most common

in men (Allodi 1974; American Psychiatric Association 1994; Robins et al. 1952). A recent study of

38 patients with conversion disorder revealed that at least one comorbid psychiatric diagnosis was

found in 89.5% of the patients (Sar et al. 2004). Dissociative disorders were present in 47.4%.

Patients with both conversion and a dissociative disorder had a high prevalence of dysthymia,

major depressive disorder, somatization disorder, and borderline personality disorder as well as a

higher prevalence of childhood emotional and sexual abuse, physical neglect, self-mutilative

behavior, and suicide attempts than those with a dissociative disorder. The authors concluded that

the presence of a dissociative disorder should alert clinicians to more chronic and severe

psychopathology among patients with conversion disorder (Sar et al. 2004). Clinicians treating

patients with conversion disorder must be aware of these comorbid conditions, because failure to

recognize and treat them may hinder the effectiveness of treatment for conversion symptoms and

may delay the treatment of potentially problematic comorbid conditions. To complicate matters, the

presence of a general medical condition does not preclude the diagnosis of conversion disorder

(American Psychiatric Association 1994).

The symptoms of conversion disorder may appear to serve a number of unconscious purposes, such

as the expression of forbidden wishes or impulses in a masked form, the imposition of

self-punishment via a disabling symptom for a forbidden wish or wrongdoing, or the removal of

oneself from an overwhelming, life-threatening situation. The symptoms are theorized to be

secondary to the repression or dissociation of memories and/or affects, the goal being symbolic

resolution of unconscious conflicts and an attempt to keep painful memories out of consciousness.

Thus, instead of “experiencing” the pain associated with certain affects, patients unconsciously

“convert” painful affects into pseudomedical symptoms, thus maintaining the dissociation of affect

from memories. Therefore, patients generally perceive themselves as victims of their symptoms.

These functions must be differentiated from those in factitious disorder, which is characterized by

feigned symptoms and the goal of being in the sick role, and from malingering, which is

characterized by feigned symptoms with external incentives (e.g., obtaining financial

compensation). In contrast, if secondary gains are present in conversion disorder, they are not the

driving factor in symptom production.

TREATMENT

General Considerations

There are several steps to be considered in the comprehensive treatment of patients with

conversion disorder (see Table 37–1). The first step is a thorough neurological and medical

evaluation. As discussed previously, neurological conditions may coexist with conversion disorder.

Moreover, several earlier researchers (Gould et al. 1962; Slater and Glithero 1965) found that when

followed longitudinally, 21%–30% of patients initially diagnosed with conversion disorder were

eventually found to have an actual neurological disorder or other organic illness that apparently

accounted for the original presentation. Other studies have found that fewer than 30% of cases of

conversion disorder are incorrectly attributed to a medical cause (Carter 1949; Dickes 1974; Folks

et al. 1984; Hafeiz 1980; Watson and Buranen 1979). Advances in medical technology and better

diagnostic techniques have dramatically improved physicians’ ability to accurately diagnose

previously “obscure” medical and neurological conditions. In fact, a 4 year follow-up study (Kent et

1. 1995) found that only 13% of patients with conversion disorder were initially misdiagnosed.

Still, the fact remains that a sizable number of patients initially diagnosed with conversion disorder

have yet-undiagnosed medical conditions (Ford and Folks 1985; Mace and Trimble 1996).Print: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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Table 37–1. Steps in the treatment of conversion disorders

1. Thorough neurological and medical evaluation
2. Timely diagnosis
3. Therapeutic reassurance by doctors that there is a good level of medical certainty that symptoms are not

due to a medical or neurological condition but are secondary to an underlying psychological conflict

4. Combined treatment that uses a medical model approach and psychological modalities to best address any

physical needs and that invites the patient to engage in treatment without feeling humiliated (addressing

psychological factors and reactions to the presented deficits is combined, if appropriate, with progressive

physical therapy to promote a sense of mastery and control)

5. Treatment of any comorbid psychiatric disorder
6. Working through the patient’s defenses and helping him or her to develop more mature and adaptive

defense mechanisms to prevent the development of future conversion episodes

A more recent study of the frequency of misdiagnosis (Stone et al. 2005) reviewed 27 studies that

included a total of 1,466 patients and a median duration of follow-up of 5 years. The authors found

a significant decline in the mean rate of misdiagnosis from the 1950s to the present day, from a

rate of 29% in the 1950s to only 4% in the 1990s. However, the authors concluded that the decline

is probably due to improvements in the quality of study design and execution rather than improved

diagnostic accuracy.

Conversely, nearly 1% of patients admitted to the general medical hospital for neurological deficits

and complaints are likely to have conversion reactions or conversion disorder (Marsden 1986). I

should also emphasize that remission in response to an acute psychiatric intervention or suggestion

of a nonphysiological symptom does not rule out the possibility of underlying nonpsychiatric

medical or neurological pathology (Fishbain and Goldberg 1991; Gould et al. 1986).

The second step is timely diagnosis. Studies show a 6- to 8-year delay before the diagnosis of

conversion disorder is made (Bowman 1993), usually because of previous misdiagnosis of and

treatment for medical, neurological, or other psychiatric conditions. The failure to make a timely

diagnosis and the use of excessive diagnostic tests or inappropriate treatments may lead to

iatrogenic problems or may “validate” the patient’s perceived deficits. Some treatments,

particularly psychoactive medications (e.g., anticonvulsants, benzodiazepines, barbiturates,

antipsychotics), may worsen conversion symptoms by causing neurological side effects (e.g.,

balance problems, memory deficits) and promote dissociative states (e.g., depersonalization,

derealization, mental slowing).

Patients with acute conversion disorder may present to the ED, urgent-care clinic, or general

practitioner’s office but are unlikely to present to the psychiatrist’s office first. The practitioner in

the more acute setting is likely to perform a routine medical workup to rule out whatever

differential diagnosis would be appropriate for the presenting symptoms. It is important not to

foster symptom deterioration or substitution by prematurely suggesting additional symptoms or

that the symptoms are “mere nerves” or “just in your head.” On occasion, a psychiatrist may serve

as a consultant in the acute setting and use amobarbital or hypnosis in this setting, but in my

experience this approach appears increasingly less common. In my clinical experience, the use of

either hypnosis or amobarbital is generally reserved for patients already admitted to a medical or

neurological unit after a comprehensive medical workup has taken place and there is a reasonable

likelihood that the symptoms are not of organic origin. If the psychiatric consult is prematurely

requested, it is imperative that the psychiatrist insist on completion of any needed medical workup

before the diagnosis of conversion disorder is considered.

The treatment of patients with conversion disorder is best carried out in collaboration with a

medical colleague (e.g., internist, primary care physician, or neurologist). In my experience, a

purely medical or purely psychiatric approach often fails. Patients often feel insulted and

abandoned when their physicians refer them to a psychiatrist or therapist, feeling there is anPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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implication that “the problem is in your head.” This usually is followed by noncompliance with the

psychiatric referral, worsening of conversion symptoms, and pursuit of a “physician who believes

me.” Therefore, a joint medical/psychiatric approach works best. Psychiatrists and therapists

should ensure that patients’ symptoms are taken seriously and that all possible medical and

neurological conditions have been considered and ruled out.

At that point, the third step in the treatment of conversion disorder involves the therapeutic

reassurance by both sets of doctors (i.e., internist or neurologist and therapist) that there is a good

level of certainty that the symptoms are not due to a medical or neurological condition but are

secondary to underlying psychological factors. It is important to present this information to

patients and their families in a manner that reassures them that powerful mechanisms are at play

and that you “know” they are not faking their symptoms and that the symptoms are not “in their

heads.” Usually, an explanation of the mind/body interaction and how unconscious and

psychological processes may affect the body in more common medical conditions is of help.

Patients often feel reassured when physicians explain that psychological factors, pressures, and

stress can create havoc in the body, as in the case of stress-induced high blood pressure, gastric

ulcers, headaches, and other psychosomatic conditions. I have found it helpful to use the analogy

between brain functioning and computers with technology-savvy patients, reassuring them that the

brain (i.e., hardware) is working well but that the mind (i.e., software) is malfunctioning, leading to

symptom formation. This analogy helps patients empathize with their own sense of powerlessness.

We must be able to assist patients with conversion disorder and symptoms to become our partners

in treatment if we want psychological interventions to have a positive impact.

Because patients experience their symptoms as real, and because often too much time passes

before the condition is properly diagnosed and adequate treatment is initiated, many patients

benefit from some form of adjunctive physical therapy or rehabilitation. Thus, if appropriate, the

fourth step combines a medical model approach and psychological modalities that can best address

any physical needs and invites the patient to engage in treatment without feeling humiliated

(Spiegel and Chase 1980). Most psychotherapeutic approaches appear to work better with

involvement of the medically appropriate consultant or modality for the presenting symptom (e.g.,

physiotherapy for a patient presenting with paralysis, speech therapy for a patient presenting with

aphonia). It is imperative at this stage for the medical/neurological team to provide adequate

reassurance that there are no medical problems that explain the symptoms or, if medical problems

are present, that the problems are unlikely to explain the deficits experienced by the patient. This

should be followed by suggestions for timely recovery and the need to find the “real cause” of the

symptoms, thus encouraging the patient to work in therapy to find the root problems for the initial

symptom presentation.

This leads to the fifth step, which involves the treatment of any psychiatric disorders that may be

present (Hurwitz 2004). Conversion disorder and conversion symptoms have not been proven to

improve with medication (but see “Pharmacologically Facilitated Interview” later in the chapter).

However, as noted earlier, comorbid major depressive disorder and anxiety disorders are common

in patients with conversion disorder (Bowman 1993; Khan et al. 2005; Roy 1980; Willinger et al.

2005; Ziegler et al. 1960) and are often highly responsive to psychopharmacological intervention in

these patients (Khan et al. 2005; Willinger et al. 2005). Other comorbid conditions, such as

dissociative disorders and personality disorders, are less likely to respond to pharmacotherapy, but

adjunctive treatment of some symptoms might be of benefit (Binks et al. 2006; Links et al. 2005;

Loewenstein 1991a, 1991b, 1994; Markowitz and Gill 1996; Putnam 1989).

The sixth step involves working through the patients’ defenses and helping them develop more

mature and adaptive defense mechanisms to prevent the development of future conversion

episodes. The ultimate goal is the development of an appropriate level of control and mastery. This

can be achieved with any number of psychotherapeutic modalities that may be used to help

patients manage their conversion symptoms. A review of the available literature suggests there are

a number of psychotherapeutic interventions that can be used to improve the symptoms and

increase the patient’s understanding of their meaning.Print: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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When a specific psychological factor is identified directly, clinical experience suggests that

addressing the stressors that may have led to the onset of conversion symptoms, including any

identified trauma, is paramount for an effective intervention. Helping patients make the connection

between recent or current stressors and earlier conflicts may allow them to understand the

significance and reason for conversion symptoms. After this is accomplished, the patients

themselves may recognize the need to address the areas of conflict, which may dramatically

ameliorate symptom severity or frequency. When one is attempting to recruit the patient as a

co-therapist, it can be helpful to remind the patient that he or she “has control” over symptom

production—albeit unconsciously. Patients are helped to understand that the symptoms presented

are indeed created by them and have a given purpose. The goal of therapy is to understand the

reason for symptom creation, the symbolism or its meaning, and the possible benefits the patient

may derive from the symptoms. This is followed by working on developing more adaptive defenses.

Clinical experience indicates that it is usually not necessary to go “on a fishing expedition”—that is,

there is seldom a need to do extensive uncovering work for possible early childhood trauma or

abuse unless a dissociative disorder is also present.

There are no good estimates of the average duration of symptoms or time to symptom resolution.

Sometimes, simply removing acute stressors or placing the patient in a protective environment

(e.g., inpatient psychiatric unit or medical ward) may lead to symptom resolution in a matter of

hours or days. Sometimes, reassurance about the absence of a medical cause along with supportive

psychotherapy achieves the same quick resolution of symptoms (Dickes 1974). Adjunctive use of

relaxation techniques, with or without formal hypnosis training, may be beneficial, often

accelerating the course of progress in therapy. If symptoms do not improve or resolve with these

approaches, a more intensive intervention may be needed. A number of techniques, used alone or

jointly, have been found useful, including pharmacologically facilitated interview (i.e.,

narcoanalysis), cognitive-behavioral approaches, and hypnotically facilitated psychotherapy. Data

have suggested that a quicker resolution of the presenting symptoms is associated with a better

prognosis (Ford and Folks 1985). Thus, it makes sense to consider one of these approaches

relatively early in the course of treatment.

Specific Techniques for Treatment of Conversion Symptoms

Table 37–2 lists specific techniques to be considered in the treatment of conversion symptoms.

Table 37–2. Specific techniques used in the treatment of conversion disorder

1. Pharmacologically facilitated interview: amobarbital or lorazepam, with or without the adjunctive use of

methylphenidate

2. Cognitive-behavioral approaches
3. In general they all combine
4. Development of a protective environment
5. Reassurance

iii. Use of relaxation techniques

1. Use of suggestive techniques
2. The main components are
3. Motivation of patients to accept the psychotherapeutic approach
4. Introduction of alternative explanations of the symptoms on the basis of both biomedical and psychosocial

mechanisms

iii. Evaluation of the new explanations by patient and therapist

1. Reduction of avoidance and inadequate illness behavior
2. Some specific approaches includePrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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1. Paradoxical intervention strategy
2. Behavior therapy reinforcement and double-bind psychotherapy

iii. Combined use of behavioral approaches and physical therapy programs

3. Hypnotically facilitated psychotherapy
4. Formal measurement of hypnotic capacity
5. Use of hypnosis to teach the patient to control rather than forcibly remove symptoms
6. Treatment steps:
7. Exploration of the meaning of symptoms
8. Symptom alteration

iii. Maximizing the patient’s level of functioning

4. Other potential treatment modalities
5. Active psychodynamic psychotherapy involving an interpretation of the metaphoric meanings of the

physical symptoms

1. Adlerian psychotherapy
2. Autogenic training
3. Biofeedback
4. Electroconvulsive therapy
5. Functional electric stimulation for psychogenic paralysis
6. Intensive physical rehabilitation or physiotherapy
7. Intravenous administration of pentothal sodium
8. Negative reinforcement
9. Operant conditioning or contingent reinforcement
10. Prokaletic (or challenging) techniques
11. Somatic therapy
12. Speech therapy using differential reinforcement
13. Transcranial magnetic stimulation

Pharmacologically Facilitated Interview

Most of the earlier literature on conversion disorder mentions the use of narcoanalysis (i.e.,

intravenous amobarbital or pentobarbital) as a diagnostic technique (Iserson 1980; Perry and

Jacobs 1982; Swartz and McCracken 1986). These authors have suggested that the narcoanalytic

interview helps confirm the diagnosis of a conversion reaction while also uncovering important

psychopathology and psychodynamic processes that may allow for more accurate diagnosis and

treatment of comorbid psychiatric disorders.

Medication-facilitated interviews have also been used as a treatment modality in acute cases of

conversion disorder and symptoms (Bradley et al. 1995; Fackler et al. 1997; Garofalo 1992; Hurwitz

1988, 2004; Iserson 1980; White et al. 1988). Some authors recommend the use of video recording

during the amobarbital sodium interview, followed by feedback during subsequent therapy sessions

(Bradley et al. 1995). Most authors have suggested limited utility in cases of chronic conversion

symptoms (Ford and Folks 1985). This approach should be used only when more conservative

approaches, such as placement in a protective environment and reassurance, have failed. The use

of barbiturates (amytal or pentobarbital) has declined in favor of the short-acting benzodiazepines

(lorazepam), given the latter drugs’ greater margin of safety (Stevens 1990). Yet others have

advocated the adjunctive use of narcoanalysis and narcosuggestion using a combination ofPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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methylphenidate and amobarbital (amobarbital produces controlled disinhibition, whereas

methylphenidate antagonizes sedation and may increase patient cooperation) (Hurwitz 1988). Still

others have recommended the use of methylphenidate without the adjunctive use of central

nervous system depressant agents to facilitate the diagnosis of conversion disorder (Burstein

1985). A detailed description of the application of medication-facilitated interviews is beyond the

scope of this chapter and has been discussed elsewhere (Iserson 1980; Perry and Jacobs 1982;

Soroglio 1984).

There are few risks when narcoanalysis is correctly implemented. However, medical risks include

oversedation or respiratory depression. Therefore, this technique should not be used in patients

with compromised respiratory or cardiac status, a history of allergy to barbiturates or

benzodiazepines, or porphyria. Laryngospasm is the most common serious potential complication;

thus, equipment for cardiorespiratory resuscitation must be readily available before starting the

procedure.

The interview should be limited to a discussion of the acute stressors leading to the conversion and

used to enhance the patient’s sense of control. A potential problem with this approach or any other

method of memory enhancement is the risk of “going on a fishing expedition”—trying to find early

psychological traumas that may account for present symptoms. This approach increases the risk of

memory contamination. Due to the potential legal ramifications of the use of any method of

memory enhancement, adequate training and supervision are recommended (Maldonado and

Spiegel 1997). The use and risks of methods of memory enhancement, including narcoanalysis and

hypnosis, have been discussed in more detail elsewhere (Maldonado and Spiegel 2003).

Cognitive-Behavioral Approaches

Several behavioral techniques have been described as useful in the treatment of conversion

symptoms (Floru 1973; McCormick 1971; Parry-Jones et al. 1970). The general principles for the

use of these techniques are the same as when applied to many other psychiatric disorders and have

been discussed at length elsewhere (Ford 1983, 1995; Wickramasekera 1997). Briefly, behavioral

techniques combine the development of a protective environment (i.e., removal from the stressful

or dangerous situation, provision of supportive and empathic therapy); reassurance from the

clinician that a full medical workup has concluded that no permanent damage has been found and

that full recovery is expected; and use of relaxation techniques (e.g., biofeedback, relaxation

training). Suggestive techniques are commonly incorporated into the behavioral treatment,

including reassurance that symptoms will improve rapidly and in fact are already improving during

the course of treatment. Given the often ruminative nature of the patient’s preoccupation with

conversion symptoms, it may be helpful to develop a behavioral therapy model that addresses the

vicious circle of etiological, triggering, and symptom-maintaining factors. Treatment-specific goals

and strategies can be derived directly from these models. The main components of treatment are 1)

motivation of patients to accept the psychotherapeutic approach; 2) introduction of alternative

explanations of the symptoms on the basis of both biomedical and psychosocial mechanisms; 3)

evaluation of the new explanations by patient and therapist; and 4) reduction of avoidance and

inappropriate illness behavior (Alford et al. 1972; Hersen et al. 1972; Mumford 1978; Von Hiller

2005).

There are no large-scale or double-blind controlled studies on the use of behavior therapy in

conversion disorder. Most of the information available comes from case reports indicating success

with this treatment approach. Techniques utilized in these reports include 1) ignoring symptomatic

behavior and therapeutic failures; 2) direct instruction and suggestion followed by increasing praise

(Agras et al. 1969; Hersen et al. 1972); and 3) operant conditioning techniques in the form of

rewards for improvement (e.g., increased privileges, home visits for inpatients) (Dickes 1974;

Gooch et al. 1997).

Most reports have suggested a better prognosis for acute rather than chronic conversion symptoms.

Shapiro and Teasell (2004), using behavioral interventions, found that 8 of 9 (89%) acutely ill

conversion disorder patients fully recovered, compared with only 1 of 28 (4%) chronically illPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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patients. The authors then applied a “paradoxical intervention strategy” (or “therapeutic double

bind”), whereby patients and their families were told that “full recovery constituted proof of an

organic etiology whereas failure to recover was definitive proof of a psychiatric etiology.” Using

this approach in patients with chronic conversion symptoms increased the success rate to 62% (13

out of 21 subjects). (This approach is complex from an ethical perspective, however.) Silver (1996)

also suggested the use of behavior therapy reinforcement and double-bind psychotherapy

strategies for more chronic or resistant symptoms, especially in cases in which there is a history of

vague or excessive somatic complaints or significant secondary gain.

Some have suggested the combined use of behavioral approaches (i.e., operant behavioral

treatment) and physical therapy similar to that provided to patients with a purely neurological

condition (Speed 1996). Others (Wald et al. 2004) have reported on the successful addition of

cognitive-behavioral therapy involving imaginary exposure to trauma memories along with

cognitive restructuring. Finally, a combination of behavioral and paradoxical techniques based on

the understanding of the dynamic material and cultural content has been proposed by Daie and

Witztum (1991).

Hypnotically Facilitated Psychotherapy

Hypnosis is a form of heightened concentration—an alert state of focused awareness—with

concomitant physical relaxation (Spiegel and Spiegel 1987) that may be useful in treating

conversion disorder. A patient with hypnotic potential can be easily trained to achieve this state of

concentration (trance state). After an appropriate patient is trained in self-hypnotic techniques, he

or she can be helped to develop the skills needed to manipulate some of his or her own bodily

sensations and functions.

In 1890, Charcot reported an association between conversion disorder and high hypnotic capacity.

He first described how hypnosis could not only alleviate conversion symptoms but also reproduce

them. More recently, Bliss (1984) reported that patients with conversion disorder tend to be very

hypnotizable, and other studies have corroborated that such patients are more highly hypnotizable

than the population at large. For example, studies suggest that 20%–30% of the general

population is highly hypnotizable, compared with nearly 70% of patients with psychogenic seizures

(Peterson et al. 1950). Similarly, Kuyk et al. (1999) found increased levels of hypnotic

susceptibility in patients with pseudoepileptic seizures than in patients with real epileptic seizures.

Roelofs et al. (2002a) found that conversion patients scored significantly higher on hypnotic

susceptibility and were more responsive to hypnotic suggestions than were control patients. In

addition, a significant correlation was found between hypnotic susceptibility and the number of

conversion complaints in patients with conversion disorder.

Indeed, it is likely that patients with a conversion disorder may be using their own hypnotic

capacity to dissociate in order to displace uncomfortable feelings or affects into a chosen body part

that then becomes dysfunctional (Maldonado 1996). Consistent with this theory, these patients

have been shown to have a high incidence of dissociative disorders or tendencies (Bowman 1993;

Marsden 1986; Roelofs et al. 2002b; Roy 1980; Ziegler et al. 1960).

Hypnosis, then, may be useful in both the diagnosis and treatment of conversion symptoms

(Bowman 1993; Bush et al. 1992; Maldonado 1996; Maldonado and Jasiukaitis 2003; Moene et al.

2003). A randomized controlled study by Moene et al. 1998) suggested that the use of suggestive

(i.e., hypnotic) and behavioral therapeutic techniques in the context of an eclectic treatment

program yielded positive results in the treatment of conversion symptoms. In another study, 44

patients with conversion disorder, motor type, or somatization disorder with motor conversion

symptoms were randomly assigned to hypnosis or a wait-list condition (Moene et al. 2003). The

patients treated with hypnosis had greater improvement (based on an observational index of

behavioral symptoms associated with the motor conversion and on an interview measure of extent

of motor disability) than those on the wait list. Improvement was maintained at 6-month follow-up.

Hypnosis should be used as an adjunct to, rather than in lieu of, medical treatment. Hypnosis is notPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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used to remove conversion symptoms but to allow patients to control the effects of emotional

stress and mind states over their bodily functions. In that sense, it is not appropriate to attempt to

cure a patient with hypnosis. In fact, clinical experience suggests that attempts to forcefully

remove a symptom usually result in worsening of the original symptom or the formation of new

symptoms (uncontrolled symptom substitution). Often patients develop symptom substitution,

usually characterized by symptoms that are more severe than the original ones, when their

defenses are threatened. A more effective approach for the clinician is to train patients in the use of

self-hypnotic techniques and allow them to improve at a pace that is comfortable for them while

providing suggestions for improved control and mastery and exploring the unconscious

psychological reasons behind the presence of the symptoms, including the possibility of secondary

gain. The therapist adopts the role of a coach, guiding the patient through the process rather than

doing things for the patient. The patient is helped through the process of understanding the nature,

meaning, and usefulness of the symptoms and is given the necessary tools to cope with the deficits

and to give up symptoms when ready.

The use of hypnosis to treat conversion disorder involves several steps (Maldonado and Spiegel

2003). The first phase involves exploring the meaning of the symptoms; it is important to never

eliminate a symptom without understanding its purpose and replacing it with a more adaptive

defense. The second phase involves symptom alteration—that is, taking the patient’s mind away

from the presenting symptoms while allowing him or her to find more appropriate ways to cope

with anxiety. This may be accomplished by symptom substitution, in which a given symptom is

exchanged for another that is less impairing or pathological until the patient is ready to give up the

original symptom (e.g., changing the perception of intense cancer pain to a numbing, tingling

sensation in the same area), or by symptom extinction, in which the patient agrees to “give up” the

symptom after working through the problem in psychotherapy. The third phase involves maximizing

the patient’s level of functioning. Hypnosis may be used to increase the patient’s motivation,

enhance his or her sense of mastery, and strengthen his or her defenses.

Other Treatment Modalities

Reports on a number of other treatment modalities for the treatment of conversion disorder have

been published. Most of these include single case reports or small sample series. Other treatment

modalities reported include transcranial magnetic stimulation (Schonfeldt-Lecuona et al. 2003);

functional electric stimulation for psychogenic paralysis (Khalil et al. 1988); negative reinforcement

(Campo and Negrini 2000); electroconvulsive therapy (Cybulska 1997; Daniel et al. 1989); active

psychodynamic psychotherapy involving an interpretation of the metaphoric meanings of the

physical symptoms (Viederman 1995); autogenic training (Oregon Garcia 1991); prokaletic (or

challenging) techniques (Neeleman and Mann 1993; Taylor 1969); biofeedback (Fishbain et al.

1988; Klonoff and Moore 1986; MacLeod and Hemsley 1985; van Harten and Schutte 1992);

Adlerian psychotherapy (Wolfle and Konig 1992); somatic therapy (Lazarus 1990); operant

conditioning or contingent reinforcement (Mizes 1985); speech therapy using differential

reinforcement (Amari et al. 1998); and intensive physical rehabilitation or physiotherapy (Heruti et

1. 2002; Letonoff et al. 2002; MacKinnon 1984; The Quality Assurance Project 1985; Watanabe et
2. 1998; Withrington and Wynn Parry 1985). Of note, there are no studies demonstrating the utility

of pharmacological agents in management or treatment of conversion disorder. The exceptions are

barbiturates, benzodiazepines, and psychostimulants, which have been shown in case reports and

series to be effective in the diagnosis and management of acute conversion disorder and the

pharmacological treatment of comorbid psychiatric conditions.

CONVERSION DISORDER IN CHILDREN AND ADOLESCENTS

Although a detailed discussion of conversion disorder in children and adolescents is beyond the

scope of this chapter, the treatment of the disorder in this population does require significant

variations from that provided to adults, including significant involvement of the family system

(Leslie 1988; Maisami and Freeman 1987; Zeharia et al. 1999). In a study of 105 patients compared

with healthy control subjects (n = 105), children with conversion reaction had a higher frequencyPrint: Chapter 37. Conversion Disorder http://www.psychiatryonline.com/popup.aspx?aID=260017&print=yes…

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of recent family stress (97%), unresolved grief reactions (58%), and family communication

problems (77%) (Maloney 1980). As in adults, comorbid psychiatric conditions are frequent among

children with conversion disorders. The predominant conversion symptoms include seizures, gait

problems, and paralysis (Lehmkuhl et al. 1989). In a study by Bhatia and Sapra (2005) of 50

children with conversion disorder, treatment with psychotherapy and medication resulted in

remission in 72%, improvement in 20%, and lack of improvement in 8% (although this study did

not include a control group).

Factors found to be associated with a positive treatment outcome in children and adolescents with

conversion disorders include younger age; healthy family functioning and personality

characteristics; lack of other psychopathology, internal conflict, and inflexible neurotic defenses;

acceptance by the family of the psychological nature of the illness; insight and compliance with

treatment; and early therapeutic intervention (Turgay 1990). Overall, the behavioral management

of conversion disorder in children appears to be as effective as in adults, although a behavioral

reward system and more systematic involvement of the family unit may be necessary for an

adequate outcome (Gooch et al. 1997).

CONCLUSION

Conversion disorder is a unique syndrome that beautifully illustrates the mind–body connection.

Both the motivation for symptom development and the mechanisms that produce symptoms are

unconscious to the patient. It is important to be aware that conversion symptoms may co-occur

with neurological or physical conditions. There are few empirical data on the treatment of

conversion disorder; nevertheless, there is reason for therapeutic optimism. Reports indicate that

various forms of psychological treatment modalities may alleviate or completely eliminate

symptoms. Psychotherapies of various types have been found effective in altering and eliminating

symptoms while helping patients work through the unconscious conflicts that appear to have

triggered the conversion. Therapeutic approaches that teach patients enhanced self-awareness of

otherwise unconscious mechanisms help patients obtain control over somatic processes. Such

treatment may resolve conversion symptoms and help patients develop better, more adaptive, and

more mature defense mechanisms, potentially preventing the development of future conversion

responses. Although data on pharmacological approaches for conversion disorder are very limited,

such treatment may be required for the treatment of comorbid psychiatric disorders.

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