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ASSIGNMENT: Understanding Psychological Disorders- II

Functional Neurological Symptom Disorder/Conversion Disorder

The term conversion disorder is relatively recent. Historically this disorder was one of several
disorders that were grouped together under the term hysteria. Conversion disorder is one of the
most intriguing and baffling patterns in psychopathology, and we still have much to learn about
it. It is characterized by the presence of neurological symptoms in the absence of a neurological
diagnosis (see Feinstein, 2011).

In other words, the patient has symptoms or deficits affecting the senses or motor behavior that
strongly suggest a medical or neurological condition. However, the pattern of symptoms or
deficits is not consistent with any neurological disease or medical problem. A few typical
examples include partial paralysis, blindness, deafness, and episodes of limb shaking
accompanied by impairment or loss of consciousness that resemble seizures.

Early observations dating back to Freud suggested that most people with conversion disorder
showed very little of the anxiety and fear that would be expected in a person with a paralyzed
arm or loss of sight. This seeming lack of concern was known as la belle indifférence—French
for “the beautiful indifference.” For a long time it was thought to be an important diagnostic
criterion for conversion disorder. However, la belle indifférence occurs only in about 20 percent
of patients. Lack of concern about symptoms or their impli cations is also not specific to
conversion disorder. For these reasons, this phenomenon has become de-emphasized in more
recent editions of the DSM

Authors of DSM-5 had many suggestions for changing the term used to describe the disorder
(e.g., to psychogenic, functional, and dissociative). In the end, a conservative approach was taken
and the term conversion disorder was retained, although this is now followed in parentheses by
“functional neurological symptom disorder”.

Clinical picture

• Prevalence
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Conversion disorders are found in approximately 5 percent of people referred for treatment at
neurology clinics. The prevalence in the general population is unknown, but even the highest
estimates have been around only 0.005 percent (APA, 2013). Conversion disorder occurs two to
three times more often in women than in men (APA, 2013).

In World War I, con version disorder was the most frequently diagnosed psychiatric syndrome
among soldiers; it was also relatively common during World War II. Conversion disorder
typically occurred under highly stressful combat conditions and involved men who would
ordinarily be considered stable.

• Onset

Onset has been reported throughout the life course. The mean onset of nonepileptic attacks peaks
at ages 20–29 years, and motor symptoms have their mean onset at ages 30–39 years. The
symptoms can be transient or persistent. The prognosis may be better in younger children than in
adolescents and adults.

It can develop at any age but most commonly occurs between early adolescence and early
adulthood (Maldonado & Spiegel, 2001). It generally has a rapid onset after a significant stressor
and often resolves within 2 weeks if the stressor is removed, although it commonly recurs
(Merkler et al., 2015).

• Symptoms/signs

The range of symptoms usually include sensory, motor, seizures or a mixed presentation of
the first categories. (APA, 2013).

- Sensory Symptoms or Deficits

Conversion disorder can involve almost any sensory modality, and it can often be diagnosed
as conversion disorder because symptoms in the affected area are inconsistent with how
known anatomical sensory pathways operate. Today the sensory symptoms or deficits are
most often in the visual system (especially blindness and tunnel vision), in the auditory
system (especially deafness), or in the sensitivity to feeling (especially the anesthesias). In
the anesthesias, the person loses her or his sense of feeling in a part of the body.
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One of the most common is glove anesthesia, in which the person cannot feel anything on
the hand in the area where gloves are worn, although the loss of sensation usually makes no
anatomical sense.

With conversion blindness, the person reports that he or she cannot see and yet can often
navigate about a room without bumping into furniture or other objects. With con version
deafness, the person reports not being able to hear and yet orients appropriately upon
“hearing” his or her own name.In general, the evidence supports the idea that the sensory
input is registered but is somehow screened from explicit conscious recognition (explicit
perception).

- Motor Symptoms or Deficits

Motor conversion reactions also cover a wide range of symptoms (e.g., Maldonado &
Spiegel, 2001; see also Stone et al., 2011). For example, conversion paralysis is usually
confined to a single limb such as an arm or a leg, and the loss of function is usually selective
for certain functions. For example, a per son may not be able to write but may be able to use
the same muscles for scratching, or a person may not be able to walk most of the time but
may be able to walk in an emergency such as a fire where escape is important.

The most common speech-related conversion disturbance is aphonia, in which a person is

able to talk only in a whisper although he or she can usually cough in a normal manner. (In
true, organic laryngeal paralysis, both the cough and the voice are affected.)

Another common motor symptom, called globus, involves the sensation of a lump in the
throat (Finkenbine & Miele, 2004).

- Seizures

Another relatively common form of conversion symptom involves seizures. These resemble
epileptic seizures, although they are not true seizures (Bowman & Markand, 2005;
Stonnington et al., 2006). For example, patients do not show any EEG abnormalities and do
not show confusion and loss of memory afterward, as patients with true epileptic seizures do.
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Moreover, patients with conversion seizures often show excessive thrashing about and
writhing not seen with true seizures, and they rarely injure themselves in falls or lose bowel
or bladder control as patients with true seizures frequently do.

- Associated Features

Cohort studies of functional neurological symptom disorder mostly show higher rates of
suicidal thoughts and attempts. Individuals with functional symptoms in a neurology clinic
have a higher rate of suicidal thoughts than individuals with recognized neurological disease

Individuals with functional neurological symptom disorder may have substantial physical
disability. The severity of disability can be similar to that experienced by individuals with
comparable recognized medical conditions.

There are many ways to differentiate between organic disorders and these subtypes of conversion
disorder. Examples of examination findings that indicate incompatibility with recognized
neurological disease include the following:

• For functional limb weakness or paralysis: Hoover’s sign, in which weakness of hip
extension returns to normal strength with contralateral hip flexion against resistance; the
hip abductor sign, in which weakness of thigh abduction returns to normal with
contralateral hip abduction against resistance; or a discrepancy between on-the-bed
performance (e.g., weakness of ankle plantar flexion) compared with another task (e.g.,
ability to walk on tiptoes).

• For functional tremor: the tremor entrainment test, in which a tremor changes when the
individual is distracted by copying the examiner in making a rhythmical movement with
the contralateral hand or foot. The test is positive when the tremor “entrains” the rhythm
of the unaffected hand or foot, the tremor is suppressed, or the individual cannot copy
simple rhythmical movements. Other features of functional limb tremor include
variability in frequency or direction of the tremor.

• For functional dystonia: individuals typically present with fixed inverted position of the
ankle, a clenched fist, or unilateral contraction of platysma, often with sudden onset.
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• For attacks resembling epileptic seizures or syncope (also called functional or
dissociative [nonepileptic] seizures): features suggestive of functional neurological
symptom disorder include persistent eye closure sometimes with resistance to opening,
bilateral motor movements with preserved awareness, or a duration longer than 5
minutes.

• For functional speech symptoms: internal inconsistencies in speech articulation and

phonation. For functional visual symptoms: a tubular visual field (i.e., tunnel vision) and
tests that indicate internal inconsistency in visual acuity, such as the “fogging test” (i.e.,
while the individual views the eye chart with both eyes open, the “good” eye is subtly
fogged so that any useful binocular vision must be a result of “bad” eye function).

• Diagnostic criteria

The symptoms in conversion disorder can simulate a variety of medical conditions, accurate
diagnosis can be extremely difficult. It is crucial that a person with suspected conversion
symptoms receive a thorough medical and neurological examination. Unfortunately, however,
misdiagnoses can still occur.

Several other criteria are also commonly used for distinguishing between conversion disorders
and true neurological disturbances:

• The frequent failure of the dysfunction to conform clearly to the symptoms of the
particular disease or disorder simulated. For example, little or no wasting away or
atrophy of a “paralyzed” limb occurs in conversion paralyses, except in rare and
long-standing cases.

• The nature of the dysfunction is highly selective: In conversion blindness the affected
individual does not usually bump into people or objects, and “paralyzed” muscles can be
used for some activities but not others.

• Under hypnosis or narcosis (a sleeplike state induced by drugs): The symptoms can
usually be removed, shifted, or reinduced at the suggestion of the therapist. Similarly, a
person abruptly awakened from a sound sleep may suddenly be able to use a “paralyzed”
limb.
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DSM -5 TR Criteria

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 condition s.

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. Coding
note: The ICD-10-CM code depends on the symptom type (see below).

Specify symptom type:

F44.4 With weakness or paralysis

F44.4 With abnormal movement (e.g., tremor, dystonia, myoclonus, gait disorder) F44.4 With
swallowing symptoms

F44.4 With speech symptom (e.g., dysphonia, slurred speech)

F44.5 With attacks or seizures

F44.6 With anesthesia or sensory loss

F44.6 With special sensory symptom (e.g., visual, olfactory, or hearing disturbance)

F44.7 With mixed symptoms

Specify if:

- Acute episode: Symptoms present for less than 6 months.

- Persistent: Symptoms occurring for 6 months or more.

Specify if: With psychological stressor (specify stressor) Without psychological stressor

• Prognosis

The general prognosis for conversion disorder is generally poor; however, this is dependent on
multiple factors. Factors that promote a good prognosis include sudden onset, early diagnosis,
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short duration of symptoms, lack of comorbid psychiatric disorders (especially personality
disorders), identifiable stressors, and a positive patient-clinician relationship. Patients with a
greater number of physical symptoms of poor physical functioning before diagnosis have an
increased chance of a poor outcome.

• Differential diagnosis

Functional neurological symptom disorder commonly coexists with recognized neurological

disease and may be part of the prodromal state of some progressive neurological diseases.

• Somatic symptom disorder: Functional neurological symptom disorder may be

diagnosed in addition to somatic symptom disorder.

• Factitious disorder and malingering: Functional neurological symptom disorder

describes genuinely experienced symptoms that are not intentionally produced (i.e., not
feigned). However, definite evidence of feigning (e.g., marked discrepancy between
reported and observed activities of daily living) would suggest malingering if the
individual’s apparent aim is to obtain an obvious external reward, or factitious disorder in
the absence of such reward.

• Dissociative disorders: Dissociative symptoms are common in individuals with

functional neurological symptom disorder. If both functional neurological symptom
disorder and a dissociative disorder are present, both diagnoses should be made.

• Body dysmorphic disorder: Individuals with body dysmorphic disorder are excessively
concerned about a perceived defect in their physical appearance but do not complain of
symptoms of sensory or motor functioning in the affected body part.

• Depressive disorders: In depressive disorders, individuals may report general heaviness

of their limbs, whereas the weakness of functional neurological symptom disorder is
more focal and prominent. Depressive disorders are also differentiated by the presence of
core depressive symptoms.

• Comorbidity
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Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur with
functional neurological symptom disorder. Somatic symptom disorder may co-occur as well.
Personality disorders are more common in individuals with functional neurological symptom
disorder than in the general population. Neurological or other medical conditions commonly
coexist with functional neurological symptom disorder as well.

Etiology

• Psychological

- Psychodynamic model

Conversion disorders are thought to develop as a result of stress or internal conflicts of some
kind. Freud used the term conversion hysteria for these disorders (which were fairly
common in his practice) because he believed that the symptoms were an expression of
repressed sexual energy—that is, the unconscious conflict that a person felt about his or her
repressed sexual desires. However, in Freud’s view, the repressed anxiety threatens to
become conscious, so it is unconsciously converted into a bodily disturbance, thereby
allowing the person to avoid having to deal with the conflict.

Freud also thought that the reduction in anxiety and intrapsychic conflict was the
“primary gain” that maintained the condition, but he noted that patients often had
many sources of “secondary gain” as well, such as receiving sympathy and attention
from loved ones.

Freud’s theory that conversion symptoms are caused by the conversion of sexual conflicts or
other psychological problems into physical symptoms is no longer accepted outside
psychodynamic circles. However, many of Freud’s astute clinical observations about primary
and secondary gain are still incorporated into contemporary views of con version disorder.

- Cognitive-behavioural model

One well-studied model suggests that exposure to information related to a specific symptom
can lead to the creation of representation in memory. Conversion disorder then occurs when
this representation is “activated” by an individual worrying excessively about or looking for
signs of the symptom. This activation passes a specific threshold in the mind, where it
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overrides sensory input and becomes an actual symptom. An example would be an individual
seeing someone have a seizure in a movie and creating a memory or a representation of this
event in their mind. Later, they encounter anxiety, light-headedness, or dizziness, and fear
that they may be experiencing symptoms preceding a seizure.

They worry about having a seizure, which activates the representation or memory of a
previously created seizure. This activated pathway causes them to have a psychogenic
non-epileptic seizure. Cognitive-behavioral models hypothesize that behavioral and
perceptual processing occurs automatically and outside of an individual’s awareness.

• Environmental/Social

Given the important role often attributed to stressful life events in precipitating the onset of
conversion disorder, it is unfortunate that little is actually known about the exact nature and
timing of these psychological stress factors (Roelofs et al., 2005).

One study compared the frequency of stressful life events in the recent past in patients with
conversion disorder and depressed controls and did not find a difference in frequency
between them. However, the greater the negative impact of the preceding life events, the
greater the severity of the conversion disorder symptoms (Roelofs et al., 2005)

Another study compared levels of a neurobiological marker of stress (lower levels of

brain-derived neurotropic factor) in individuals with conversion disorder versus major
depression versus no disorder. Both those with depression and those with conversion disorder
showed reduced levels of this marker relative to the non disordered controls (Deveci et al.,
2007). This also provides support for the link between stress and the onset of conversion
disorder.

• Biological

The largest functional neuroimaging study of sensory conversion disorder involves 10 female
patients (Burke et al., 2014). Again, the findings suggest that when the anesthetic body part is
stimulated, there is decreased activation in the somatosensory cortex but increased activation
in areas such as the anterior cingulate cortex, insula, and other brain areas implicated in
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emotion processing. All of this is consistent with the idea that sensory areas may perhaps be
being inhibited by overactive emotion based processing.

Strange as it may seem, what may be happening in patients with conversion disorders is that
abnormal activation in limbic areas (or areas connected to them) might be overriding
activation in motor or sensory areas, shutting off the person’s ability to detect stimuli
(in the case of anesthesia) or move a limb.

Case study

Patient: Calire
Age: 28
Background: Claire is a 28-year-old woman who works as a marketing executive in a busy
firm. She has a history of childhood trauma related to emotional neglect and has experienced
periods of anxiety and depression throughout her life. Claire has been struggling with stress at
work due to increasing pressure to meet deadlines and performance expectations. She is also
dealing with relationship issues with her partner, adding to her emotional distress.

Presenting Problem:
Claire was brought to the emergency room by her partner after she suddenly collapsed at
work. She complained of weakness in her legs and difficulty walking. Upon examination, no
neurological abnormalities were found, and all tests, including brain imaging and blood work,
came back normal. Despite reassurance from medical professionals that there was no physical
cause for her symptoms, Claire remained convinced that she was paralyzed and unable to
move her legs.

Assessment and Diagnosis:

Claire's symptoms were consistent with functional neurological symptom disorder (FNSD),
formerly known as conversion disorder. FNSD is characterized by neurological symptoms,
such as weakness or paralysis, that cannot be attributed to a medical condition and are
believed to be caused by psychological factors.

Treatment Plan:
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Claire was referred to a psychiatrist specializing in FNSD for further evaluation and
treatment. The treatment plan included cognitive-behavioral therapy (CBT) to address
underlying psychological issues and help Claire cope with stress and anxiety. Claire also
participated in physical therapy sessions aimed at gradually reintroducing movement and
functionality to her legs.
Outcome:
Over the course of several weeks of therapy, Lisa began to show improvement in her
symptoms. Through CBT, she gained insight into the connection between her emotional
distress and physical symptoms. With the support of her therapist, she developed coping
strategies to manage stress and anxiety more effectively. Additionally, the physical therapy
sessions helped Lisa regain confidence in her ability to move her legs, and she started to walk
with assistance.

Conclusion

Functional Neurological Symptom Disorder (FNSD), formerly conversion disorder, presents

with neurological symptoms lacking a medical basis. It's more common in women, often
triggered by stress, and can manifest as sensory, motor, or seizure-related issues. Diagnosis is
challenging, requiring exclusion of organic causes.

Treatment for conversion disorder typically involves a multidisciplinary approach tailored to

the individual's needs. Cognitive-behavioral therapy (CBT) is often the first-line treatment,
focusing on identifying and challenging negative thought patterns and behaviors. Physical
therapy helps reintroduce normal movements for functional motor symptoms, while
medications like antidepressants may be prescribed for underlying mental health
conditions.Overall, a comprehensive care team of healthcare professionals is essential to
develop personalized treatment plans and provide support for patients and their families.

References

Alloy, L. (2008). Abnormal Psychology: Current Perspectives with MindMAP Plus CD-ROM.
McGraw-Hill Education.
Association, A. P. (2022). Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR.
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Hooley, J. M., Nock, M., & Butcher, J. N. (2020). Abnormal Psychology, Global Edition.
Pearson.
Peeling, J. L., & Muzio, M. R. (2023, May 8). Conversion disorder. StatPearls - NCBI
Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK551567/