ppt

1. FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER
/CONVERSION DISORDER
Presenter: Zeleke W/Y (NR-II)
Moderator: Dr. Sewbesew Y (Consultant
Psychiatrist)
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2. Outline of the seminar
• Case Presentation
• Introduction
• Epidemiology
• Clinical features
• Treatment
• Reference
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3. Case presentation
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4. Contd....
• meeting and was unable to speak. She presented herself at the
emergency room, and her boss was notified of her hospitalization.
She was released when nothing physiological could be found. Today is
the day of Carol’s scheduled presentation. She has again awakened
with the inability to make a sound. She has presented herself to the
ER and does not appear to be very concerned about the problem. The
admitting emergency room physician cannot find anorganic reason
for her aphonia. A psychiatrist is notified, and Carol is admitted to the
psychiatric unit.
• Diagnosis???
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5. INTRODUCTION
• Conversion disorder aka functional neurologic symptom disorder is
characterized by neurologic symptoms, such as weakness, abnormal
movements, or nonepileptic seizures,
• Involve abnormal nervous system functioning rather than structural
disease.
• The disorder is common in clinical settings, causes distress and/or
impairment, and often has a poor prognosis
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6. Contd....
• Conversion disorder is formerly known as ’hysteria’.
• The term ‘hysteria’, derived from the Greek word for womb or uterus,
implied an unwanted migration of the organ to higher sites.
• The term conversion disorder was used by Sigmund Freud and his
collague/mentor Josef Breuer.
• Hypothesized that the symptoms of conversion reflect unconscious
conflict.
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7. Contd....
• In 1895, they wrote ‘Studies on Hysteria’
• Their most famous case was a female called ‘Anna O’ (her real name is
Bertha Pappenheim)
• Her symptoms was paralysis,visual impairement and amnesia
• She coined the phrase ‘’Talking cure.”
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8. Contd....
Definition
• A conversion reaction is a rather acute and temporary loss or alteration in motor
or sensory function, not compatible with known neurological disorders.
• The word ‘conversion’ is used as assumption is that psychological distress is
‘converted’ into physical (usually neurological) symptoms.
• The problem is that stress is omnipresent in life, and many patients present with
conversion when no stressor has been demonstrated.
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9. Contd....
• Definition according to the DSM-5:
• Conversion disorder, also called functional neurological symptom
disorder is defined as an illness of symptoms or deficits that affect
voluntary motor or sensory functions.
• Caused by psychological factors at which the illness is preceded by
conflicts or other stressors.
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10. Contd....
• Characteristic features of the symptoms or deficits of conversion disorder are:
not intentionally produced
not caused by substance use and
not limited to pain or sexual symptoms
• Note that the gain is primarily psychological and not social, monetary, or legal
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11. Contd....
• DSM-5 made two crucial modifications:
• First, it appended a parenthetical diagnosis (“functional neurological
symptom disorder”)
• Second, it clarifies that the diagnosis is made when the symptom is
incompatible with known neurological disorders.
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12. EPIDEMIOLOGY
• The estimated incidence across disparate geographical settings was 4
to 12 per 100,000 per year.
• Several studies have reported that 5 to 15 percent of psychiatric
consultations in a general hospital involve patients with conversion
disorder diagnoses.
• Accounts for 25-30% of admissions
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13. Contd....
• It is more common in females in both adults and children.
• About half presents with multiple symptoms.
• More common in those with lower level of education particularly lack
of medical knowledge.
• Affects commonly those with lower socio-economic classses.
• Typical age range is 10-35 years old.
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14. ETIOLOGY AND PATHOGENESIS
• The etiology and pathogenesis of conversion disorder (functional
neurologic symptom disorder) are not clear.
• There are many biological, psychological, and social factors.
• These factors may predispose patients to conversion disorder or
precipitate and/or perpetuate symptoms.
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15. Contd....
• Personality factors
‘’la belle indifference’’
 Histrionic personality
• Biological factors
There is inherent defect in certain brain functions, especially those in
the dominant hemisphere that may interfere with verbal
associations.
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16. Contd....
• There are abnormalities in neural networks of grey matter brain
regions.
• Networks include frontal (orbitofrontal and anterior cingulate cortex)
and subcortical (limbic) structures.
• One hypothesis is that overly sensitive amygdala responses to fear
which leads to changes in networks mediating sensory and motor
function.
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17. Contd....
• Neuroimaging shows there is predominantly functional CNS changes,
but also possibly structural changes.
• Structural MRI studies found evidence of altered brain structure in
patients (eg, increased thalamic volume and decreased sensorimotor
cortical thickness)
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18. Psychological factors
• The behavioral theory attributes conversion disorder to faulty
childhood learning, with the nonadaptive behavioral responses used
for secondary gain and control of interpersonal relationships.
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19. Contd....
• The psychoanalytic theory describes symptoms as compromise
formations with primary gain of conflict resolution through a partial
expression of the conflict without conscious awareness of its
significance.
• Unconscious psychological distress is converted to obvious physical
symptoms.
• Non-verbal communication of forbidden ideos or feelings.
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20. Contd....
• Conversion of anxiety into a physical symptom.
• The conversion disorder symptom has symbolic relation to the
unconscious conflict (e.g. vaginismus with sexual desire, syncope with
arousal, paralysis with anger)
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21. A range of potential etiologic factors in patients with
functional symptoms
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23. DIAGNOSIS
• Diagnosis is based on overall clinical picture, not a single clinical finding.
• those symptoms that affect a voluntary motor or sensory function.
• The diagnosis requires that clinicians find a necessary and critical association
between the cause of the neurological symptoms and psychological factors.
• The symptoms cannot result from malingering or factitious disorder.
• i.e. symptoms are real, patient can’t fake or intentionally produce them.
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24. Contd....
• The diagnosis of conversion disorder also excludes symptoms of pain
and sexual dysfunction and symptoms that occur only in somatization
disorder.
• The main features of conversion disorder is inconsistency between
presenting symptoms and an underlying organic pathology.
• There is often functional ovelay.
• Patients do not have conscious control over their symptoms.
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25. DSM 5 Diagnostic Criteria For Conversion Disorder
• A. One or more symptoms of altered voluntary motor or sensory function.
• B. Clinical findings provide evidence of incompatibility between the symptom and
recognized neurological or medical conditions.
• C. The symptom or deficit is not better explained by another medical or mental
disorder.
• D. The symptom or deficit causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning or warrants medical
evaluation.
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26. Contd....
• Symptom specifiers
With weakness or paralysis
With abnormal movement
With swallowing symptoms
With speech symptom
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptoms
(i.e., vision, olfaction, hearing)
With mixed symptoms
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27. Contd....
• Course specifiers
Acute episode (<6 mo)
Persistent (≥6 mo)
• Specify stressors
With psychological stressor
Without psychological stressor
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28. COMORBID DISORDERS
• Psychiatric disorders: in up to 90% or more of patients with
conversion disorder.
• Multiple prospective studies found that frequency of comorbid
disorder in patients with conversion disorder exceeds the frequency
in patients with defined neurologic disease.
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29. Contd....
• Commonly coexisting psychiatric disorder includes:
Personaliy disorder(especially cluster B)
Anxiety disorder
Depression
Bipolar disorder
PTSD
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30. CLINICAL FEATURES
• Symptoms recognized by DSM-5 include
(from most to least common):
Nonepileptic seizures (most common)
Weakness and paralysis
Abnormal movement
Speech symptoms
Globus sensation (swallowing
symptoms)
Sensory symptoms
Cognitive symptoms (least)
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31. Contd....
• Motor symptoms are more common.
• Nonneurological syndromes such as pseudocyesis (false pregnancy) or
psychogenic vomiting have also been placed under the conversion disorder
category.
• Patients with conversion disorder usually present with symptoms suggestive
of neurological disease such as muscle weakness, gait disturbance, blindness,
aphonia, deafness, convulsions, or tremors.
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32. Sensory symptoms or deficits
• Sensory symptoms that is incongruent with known nerve pathways.
• All sensory modalities can be involved.
• Sensory symptoms or deficits:
Impaired vision (hysterical blindness), double vision
Impaired hearing (deafness)
Loss or disturbance of touch or pain sensation such as anesthesia and
paresthesia
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33. Contd....
• Symptoms may involve the organs of special sense and can produce
deafness, blindness, and tunnel vision.
• E.g.blindness, patients walk around without collisions or self-injury,
their pupils react to light, and their cortical-evoked potentials are
normal.
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34. Visual symptoms (functional visual disturbance)
• Conversion visual symptoms include:
intermittent blurred vision
double vision
nystagmus
visual field defects, and
complete blindness
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35. Contd....
• In patients with complete binocular blindness, specific tests for
conversion disorder with visual symptoms include the following
Fingertip test
Signature test
Menace reflex (vision threat test)
Tearing reflex
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36. Motor Symptoms
• Include abnormal movements, gait disturbance, weakness, and
paralysis.
• E.g. of gait disturbance is astasia-abasia, is inability to either stand or
walk with unsupported, with jerky bodily movements and waving of
arms.
Patients rarely fall; if they do, they are generally not injured.
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37. Contd....
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38. Abnormal movement
• Functional movement disorders (FMDs)
Functional tremor (most common type)
Functional dystonia
Functional gait disorder
Functional myoclonus
Functional Parkinsonism
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39. Contd....
• Other common motor disturbances are paralysis and paresis involving
one, two, or all four limbs.
the distribution of the involved muscles does not conform to the
neural pathways.
• Reflexes remain normal
• There is no fasciculations or muscle atrophy (except after long-standing
conversion paralysis); electromyography findings are normal.
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40. Motor symptoms:Seizure/PNES
• Clinicians may find it difficult to differentiate a pseudoseizure/PNES
from an actual seizure by clinical observation alone.
• 1/3 of those with Pseudoseizures have coexisting epileptic disorder
• Most reliable signs distinguish PNES from epileptic seizure include:
long duration and fluctuating course
asynchronous movements and pelvic thrusting
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41. the most reliable signs....
side-to-side head or body movements
ictal eye closure and crying
memory recall, and
absent postictal confusion
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43. Contd....
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GTC epileptic seizures Convulsive PNES
Aura less common more common(25 to 60%)
Onset Commonly sudden Often gradual
Injury Commonly reported/observed Less commonly reported/observed
Burn Thermal Friction
Tongue/mouth injury Bite to lateral tongue or inside of
cheek, observed injury
Reported bite to tip of tongue
Stereotypy Usual Common
Defecation and micturition frequent never
Termination spontaneous spontaneous, sometimes artifcially
induced
Respiratory changes stertorous breathing pattern shallow, rapid respirations

44. Contd....
• Psychiatric conditions associated with PNES include:
Depression
Anxiety
Somatic symptom and related disorders
Post-traumatic stress disorder
Dissociative disorders
Personality disorders
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45. Motor symptoms:Speech
• The most common conversion speech symptom is functional
dysphonia, which usually presents as whispering or hoarseness.
• There is also loss of speech (hysterical aphonia)
• Clues that the speech impairment is related to a functional disorder
include the presence of a normal cough or singing voice.
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46. Other motor symptoms or deficits
• Difficulty swallowing (dysphagia) or a sensation of a lump in the
throat/globus sensation or globus pharyngeus
• Urinary retention
• Loss of consciousness (fainting)
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47. Cognitive symptoms
• Cognitive symptoms that are commonly encountered in patients with
conversion disorder include:
Poor concentration and memory
Impaired fluency
Jumbling of words when speaking
Word finding difficulty
Variability in speed of response
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48. Associated Psychological symptoms
• PRIMARY GAIN: Patients achieve primary gain by keeping internal conflicts
outside their awareness.
• i.e.internal psychological benefit.
• Symptoms have symbolic value; they represent an unconscious psychological
conflict.
• SECONDARY GAIN: refers to external practical benefit.
• Due to physical symptoms, patient can avoid usual responsiblities.
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49. Contd....
• LA BELLE INDIFFÉRENCE. French term, literally means “ the beautiful
indifference”
• It is a patient’s inappropriately cavalier attitude toward severe
symptoms.
• i.e the patient seems to be unconcerned about what appears to be
a significant impairment.
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50. Contd....
• Identification
• Unconscious modeling of symptoms after someone considered
important to the patient
• With pathological grief reaction, bereaved persons commonly have
symptoms of the deceased.
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51. Physical Examination
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• The key diagnostic finding in conversion weakness or paralysis is that
the deficit is inconsistent at different times in the examination.
• Positive signs of functional weakness on physical examination include
the following:

52. Contd....
• Obvious inconsistencies – Examples include:
No ankle plantar flexion while lying down, but the ability to stand
on tip toes
Inability to move arm during examination, but able to use arm to
take something out of a bag or put shoes back on
• Hoover sign
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53. Contd....
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54. Contd....
• Hip abductor sign – Comparable with
Hoover sign, when the hip abductor sign is
positive, hip abduction weakness in the
affected leg returns to normal during
contralateral hip abduction against
resistance in the unaffected.
• However, pain may result in a false positive.
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55. Contd....
• Co-contraction sign – It is the simultaneous contraction of agonist and
antagonist muscles.
• During muscle strength testing of the agonist (eg, the biceps) in
patients with conversion disorder, the clinician may be able to detect
contraction of the antagonist (eg, the triceps).
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56. Contd....
• Give-way or collapsing weakness
• The patient is asked to exert force in a particular direction, and as the examiner
lightly exerts force in the opposite direction, the examiner feels an abrupt
decrease in resistance as the patient’s extremity gives way suddenly.
• But, it is not good indicator of functional (psychogenic) weakness.
• Other causes of give-way weakness include chorea, pain, joint problems, and
failure to understand instructions.
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57. Contd....
• A delayed, slow, or jerky descent when the clinician positions the
outstretched arm in front of the patient and then releases it.
• A global or inverted pyramidal pattern of weakness in the legs (eg,
extensors weaker than flexors)
• Drift without pronation sign
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58. Summary:Distinctive P/E Findings
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59. P/E findings....
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60. P/E findings....
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61. Treatment
• The first line treatment of conversion disorder begins with education
about the syndrome.
Ask patients what they think is wrong and reassure that brain
hardware is healthy.
State that the symptoms are real and are reversible.
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62. Contd....
Provide a diagnosis rather than simply telling patients that “there is
no disease.”
Emphasize the mechanism underlying the symptoms rather than the
cause.
Where relevant, explain that the patient does not have a neurologic
disease such as multiple sclerosis, epilepsy, or stroke.
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63. Contd....
Discuss that it is important to identify and treat comorbid depression
and anxiety because they can worsen conversion symptoms.
Tell patients that although they did not bring about the symptoms,
they need to actively participate in their rehabilitation
Acknowledge any prior treatment that was unsatisfactory.
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64. PSYCHOTHERAPY
• Many conversion syndromes have an acute, benign course and may remit
spontaneously with understanding and support.
• Once chronicity has developed, intensive treatment may use all
treatment modalities include:
hospitalization
individual or group therapy
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65. Contd....
insight-oriented therapies
behavioral techniques
physical therapy, biofeedback
relaxation training, and medication
• Reassuring the patients that critical tests are normal and that symptoms
will eventually improve may be helpful.
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66. Contd....
• Behavioral interventions should focus on improving self-esteem, the
capacity for emotional expression and assertiveness, and the ability
to communicate comfortably with others.
• For symptoms other than functional motor symptoms that do
respond to education, we suggest CBT as second line therapy.
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67. Hypnotherapy
• It employs the use of hypnosis may be useful for patients with
conversion disorder that includes symptoms of sensory loss or speech
disturbance.
• In addition, hypnosis lends itself to introducing relaxation techniques
for patients who do not want psychotherapy.
• It the oldest treatment used for conversion disorder.
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68. Physiotherapy
• For conversion disorder with functional motor symptoms, we suggest
physical therapy as second line therapy.
• CBT, is often used as well, either concurrently or sequentially.
• It is essential for patients who acquire a physical disability (eg,
contractures with chronic conversion)
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69. Contd....
• Treatment is based upon a biopsychosocial etiological model.
• It is directed at changing illness beliefs, decreasing abnormal self-
directed attention, and reducing abnormal movements through
Education
Eliciting normal movements
Movement retraining by diverting attention
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70. Pharmacotherapy
• Accompanying comorbid depression, anxiety, and behavior problems
may respond to pharmacologic interventions.
• The most commonly used drugs for conversion disorder are
antidepressants.
• Comorbid anxiety or depressive disorders are often an indication to
use antidepressants, such as SSRIs.
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71. COURSE AND PROGNOSIS
• Almost 95% of acute cases remit spontaneously, usually within 2
weeks in hospitalized patients.
• Prognosis is inversely related with duration of the symptoms.
E.g. if symptoms stay more than or equals to 6 months probability
of symptoms resulution become less than 50%.
• Recurrence within 1 year of first episode occurs in 20-25% of people.
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72. Contd....
• Indicators of good prognosis
 Onset in childhood or adolescence
 Early diagnosis
 Good response to initial treatment
 Comorbid anxiety or depression
 Presence of clearly identifiable
stressors at the time of onset
 A short interval between onset and
the institution of treatment
 Paralysis, aphonia, and blindness
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73. Contd....
• Indicators of poor prognosis
 Multiple physical symptoms
 Longer duration of symptoms
 Poor physical functioning
 Comorbid personality disorder
 Seizure and tremor
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74. REFERENCES
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Uptodate 2022

75. THANK YOU!!!
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