Conversion disorder is largely managed by neurologists, for whom it presents
great challenges to understanding and management. This study aimed to
quantify these challenges, examining how neurologists understand conversion
disorder, and what they tell their patients.
A postal survey of all consultant neurologists in the UK registered with the
Association of British Neurologists.
349 of 591 practising consultant neurologists completed the survey. They saw
conversion disorder commonly. While they endorsed psychological models for
conversion, they diagnosed it according to features of the clinical
presentation, most importantly inconsistency and abnormal illness behaviour.
Most of the respondents saw feigning as entangled with conversion disorder,
with a minority seeing one as a variant of the other. They were quite
willing to discuss psychological factors as long as the patient was
receptive but were generally unwilling to discuss feigning even though they
saw it as their responsibility. Those who favoured models in terms of
feigning were older, while younger, female neurologists preferred
psychological models, believed conversion would one day be understood
neurologically and found communicating with their conversion patients easier
than it had been in the past.
Neurologists accept psychological models for conversion disorder but do not
employ them in their diagnosis; they do not see conversion as clearly
different from feigning. This may be changing as younger, female
neurologists endorse psychological views more clearly and find it easier to
discuss with their patients.
Neurologists face a dilemma when communicating with their conversion disorder patients – whether to be frank, and risk losing the patient's trust, or to disclose less, in the hope of building a therapeutic relationship. This study reports how neurologists in the UK described dealing with this dilemma in their practice.
Practicing consultant neurologists from an NHS region were recruited by snowball sampling. Twenty-two of 35 consultants in the region were interviewed in depth, and the interviews qualitatively analysed.
The neurologists were reluctant to disclose conversion disorder as a differential diagnosis until they were certain. They were guided by the receptivity of their patients as to how psychological to make their eventual explanations, but they did not discuss their suspicions about feigning. They described their communications as much easier now than they had seen in training.
Neurologists adapt their disclosure to their patients, which facilitates communication, but imposes some limits on truth-telling. In particular, it may sometimes result in a changed diagnosis.
An optimum strategy for communicating diagnoses will need to balance ethical considerations with demonstrated therapeutic benefit.
Conversion disorder; Factitious disorder; Malingering; Hysteria; Truth-telling; Deception; Neurology
The term ‘functional’ has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean ‘hysterical’. The DSM-V working group proposes to use ‘functional’ as the official diagnostic term for medically unexplained neurological symptoms (currently known as ‘conversion disorder’). This study aimed to explore the current neurological meanings of the term and to understand its resilience.
Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.
The interviews revealed four dominant uses—‘not organic’, a physical disability, a brain disorder and a psychiatric problem—as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of ‘functional’ to mean only ‘not organic’, but a minority employing it to mean different things in different contexts - and endorsing the view that ‘functional’ would one day be a neurological construct again.
‘Functional’ embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.
This article provides a neurobiological account of symptoms that have been called ‘hysterical’, ‘psychogenic’ or ‘medically unexplained’, which we will call functional motor and sensory symptoms. We use a neurobiologically informed model of hierarchical Bayesian inference in the brain to explain functional motor and sensory symptoms in terms of perception and action arising from inference based on prior beliefs and sensory information. This explanation exploits the key balance between prior beliefs and sensory evidence that is mediated by (body focused) attention, symptom expectations, physical and emotional experiences and beliefs about illness. Crucially, this furnishes an explanation at three different levels: (i) underlying neuromodulatory (synaptic) mechanisms; (ii) cognitive and experiential processes (attention and attribution of agency); and (iii) formal computations that underlie perceptual inference (representation of uncertainty or precision). Our explanation involves primary and secondary failures of inference; the primary failure is the (autonomous) emergence of a percept or belief that is held with undue certainty (precision) following top-down attentional modulation of synaptic gain. This belief can constitute a sensory percept (or its absence) or induce movement (or its absence). The secondary failure of inference is when the ensuing percept (and any somatosensory consequences) is falsely inferred to be a symptom to explain why its content was not predicted by the source of attentional modulation. This account accommodates several fundamental observations about functional motor and sensory symptoms, including: (i) their induction and maintenance by attention; (ii) their modification by expectation, prior experience and cultural beliefs and (iii) their involuntary and symptomatic nature.
attention; sensorimotor information processing; cognitive neuroscience
The diagnostic preferences of British neurologists for patients who lack a physical explanation for their symptoms were assessed by means of a postal questionnaire. Analysis of 168 completed replies showed 'functional', 'psychogenic' and 'hysteria' to be the most popular terms in use. The number of different terms a clinician would use rose in line with the volume of such patients they encountered, but was unrelated to clinician factors such as the extent of their clinical experience in psychiatry. A specific enquiry into these respondents' interpretation of the term 'functional' revealed a clear consensus as to which syndromes it should apply to, although this consensus was not shared by a comparison group of psychiatrists.
Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.
Objective Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as “conversion” symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging.
Design Systematic review.
Data sources Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists.
Review methods We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data.
Results Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies.
Conclusions A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.
Conversion disorder has a history that may reach back into antiquity, and it continues to present a clinical challenge to both psychiatrists and neurologists. This article reviews the current state of knowledge surrounding the prevalence, etiology, and neurobiology of conversion disorder. There have been improvements in the accuracy of diagnosis that are possibly related to improved technologies such as neuroimaging. Once the diagnosis is made, it is important to develop a therapeutic alliance between the patient and the medical team, and where comorbid psychiatric diagnoses have been made, these need to be adequately treated. While there have been no formal trials of medication or psychoanalytic treatments in this disorder, case reports suggest that a combination of antidepressants, psychotherapy, and a multidisciplinary approach to rehabilitation may be beneficial.
conversion disorder; hysteria; diagnosis
Simulation can be defined as malingering, or sometimes functional visual loss (FVL). It manifests as either simulating an ophthalmic disease (positive simulation), or denial of ophthalmic disease (negative simulation). Conscious behavior and compensation or indemnity claims are prominent features of simulation. Since some authors suggest that this is a manifestation of underlying psychopathology, even conversion is included in this context. In today's world, every ophthalmologist can face with simulation of ophthalmic disease or disorder. In case of simulation suspect, the physician's responsibility is to prove the simulation considering the disease/disorder first, and simulation as an exclusion. In simulation examinations, the physician should be firm and smart to select appropriate test(s) to convince not only the subject, but also the judge in case of indemnity or compensation trials. Almost all ophthalmic sensory and motor functions including visual acuity, visual field, color vision and night vision can be the subject of simulation. Examiner must be skillful in selecting the most appropriate test. Apart from those in the literature, we included all kinds of simulation in ophthalmology. In addition, simulation examination techniques, such as, use of OCT (optical coherence tomography), frequency doubling perimetry (FDP), and modified polarization tests were also included. In this review, we made a thorough literature search, and added our experiences to give the readers up-to-date information on malingering or simulation in ophthalmology.
malingering; simulation; conversion; hysteria
Simulation can be defined as malingering, or sometimes functional visual loss (FVL). It manifests as either simulating an ophthalmic disease (positive simulation), or denial of ophthalmic disease (negative simulation). Conscious behavior and compensation or indemnity claims are prominent features of simulation. Since some authors suggest that this is a manifestation of underlying psychopathology, even conversion is included in this context. In today's world, every ophthalmologist can face with simulation of ophthalmic disease or disorder. In case of simulation suspect, the physician's responsibility is to prove the simulation considering the disease/disorder first, and simulation as an exclusion. In simulation examinations, the physician should be firm and smart to select appropriate test(s) to convince not only the subject, but also the judge in case of indemnity or compensation trials. Almost all ophthalmic sensory and motor functions including visual acuity, visual field, color vision and night vision can be the subject of simulation. Examiner must be skillful in selecting the most appropriate test. Apart from those in the literature, we included all kinds of simulation in ophthalmology. In addition, simulation examination techniques, such as, use of optical coherence tomography, frequency doubling perimetry (FDP), and modified polarization tests were also included. In this review, we made a thorough literature search, and added our experiences to give the readers up-to-date information on malingering or simulation in ophthalmology.
malingering; simulation; conversion; hysteria
This paper analyses how, prior to the work of Sigmund Freud, an understanding of infant and childhood sexuality emerged during the nineteenth century. Key contributors to the debate were Albert Moll, Max Dessoir and others, as fin-de-siècle artists and writers celebrated a sexualised image of the child. By the beginning of the twentieth century, most paediatricians, sexologists, psychologists, psychiatrists, psychoanalysts and pedagogues agreed that sexuality formed part of a child’s ‘normal’ development. This paper argues that the main disagreements in discourses about childhood sexuality related to different interpretations of children’s sexual experiences. On the one hand stood an explanation that argued for a homology between children’s and adults’ sexual experiences, on the other hand was an understanding that suggested that adults and children had distinct and different experiences. Whereas the homological interpretation was favoured by the majority of commentators, including Moll, Freud, and to some extent also by C.G. Jung, the heterological interpretation was supported by a minority, including childhood psychologist Charlotte Bühler.
Childhood Sexuality; Child–Woman; Psychology; Psychoanalysis; Sexology; Charlotte
Bühler; Max Dessoir; Havelock Ellis; Wilhelm Fließ; Sigmund Freud; Carl Gustav Jung; Karl Kraus; Sámuel Lindner; Albert Moll; Egon Schiele; Wilhelm Stekel; William Stern; Fritz Wittels
Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.
Developmental coordination disorder (DCD)
is a common motor problem affecting—even in
rather severe form—several percent of school
age children. In the past, DCD has usually been
called ‘clumsy child syndrome’ or ‘non-cerebralpalsy
motor-perception dysfunction’. This
disorder is more common in boys than in girls
and is very often associated with psychopathology,
particularly with attention-deficit/hyperactivity
disorder (ADHD) and autism spectrum disorders/
autistic-type problems. Conversely, children
with ADHD and autism spectrum problems,
particularly those given a diagnosis of Asperger
syndrome, have a very high rate of comorbid
DCD. Psychiatrists appear to be unaware of this
type of comorbidity in their young patients.
Neurologists, on the other hand, usually pay
little attention to the striking behavioral and
emotional problems shown by so many of their
‘clumsy’ patients. A need exists for a much
clearer focus on DCD—in child psychiatry and
in child neurology—both in research and in
Monetary incentives are an effective way of increasing response rates to surveys, though they are generally less effective in physicians, and are more effective when the incentive is paid up-front rather than when made conditional on completion.
In this study we examine the effectiveness of pre- and post-completion incentives on the response rates of all the neurologists in the UK to a survey about conversion disorder, using a cluster randomised controlled design. A postal survey was sent to all practicing consultant neurologists, in two rounds, including either a book token, the promise of a book token, or nothing at all.
Three hundred and fifty-one of 591 eligible neurologists completed the survey, for a response rate of 59%. While the post-completion incentive exerted no discernible influence on response rates, a pre-completion incentive did, with an odds-ratio of 2.1 (95% confidence interval 1.5 - 3.0).
We conclude that neurologists, in the UK at least, may be influenced to respond to a postal survey by a pre-payment incentive but are unaffected by a promised reward.
Subject enrolled in the Autopsy Program at the University of Southern California Alzheimer’s Disease Research Center may receive clinical diagnoses from primary care providers in the community or from specialists in neurology. We reviewed the autopsy concordance rates for 463 subjects for diagnoses made by both groups of clinicians. Seventy-seven percent of the sample met neuropathological criteria for Alzheimer’s disease (AD). The overall diagnostic accuracy for this sample was 81 percent. Neurologists assessed 200 of the subjects (43 percent). The diagnostic accuracy for any clinical diagnosis among the non-neurologists was 84 percent, and 78 percent (p = 0.07) among neurologists. For AD, non-neurologists had a diagnostic concordance rate of 91 percent and neurologists 87 percent. Where neuropathological AD was missed, non-neurologists had failed to detect any cognitive impairment; neurologists had diagnosed Parkinson’s disease (PD) and amyotrophic lateral sclerosis (ALS). Erroneous clinical diagnoses of AD missed dementia with Lewy bodies (DLB) or AD concurrent with Parkinson’s disease (PD). Our findings identify specific foci for improving clinical diagnosis of dementia among all physicians managing dementia.
Alzheimer’s disease; autopsy; cerebrovascular disease; clinical audit; dementia; diagnostic accuracy
Conversion paresis patients and healthy people feigning weakness both exhibit weak voluntary movement without detectable neuropathology. Uniquely, conversion patients lack a sense of conscious awareness of the origin of their impairment. We investigated whether conversion paresis patients show distinct electroencephalographic (EEG) markers associated with their unconscious movement deficits.
Six unilateral upper limb conversion paresis patients, 12 feigning participants asked to mimic weakness and 12 control participants performed a precued reaction time task, requiring movements of either hand, depending on precue information. Performance measures (force, reaction and movement time), and event-related EEG potentials (ERP) were compared, between groups and across hands or hemisphere, using linear mixed models.
Feigners generated the same inter-hand difference in reaction and movement time as expressed by patients, even though no specific targets were set nor feedback given on these measures. We found novel ERP signatures specific to patients. When the symptomatic hand was precued, the P3 ERP component accompanying the precue was dramatically larger in patients than in feigning participants. Additionally, in patients the earlier N1 ERP component was diminished when the precue signalled either the symptomatic or asymptomatic hand.
These results are consistent with previous suggestions that lack of awareness of the origin of their symptoms in conversion disorder patients may result from suppression of brain activity normally related to self-agency. In patients the diminished N1 to all precues is consistent with a generalised reduction in cognitive processing of movement-related precues. The P3 enhancement in patients is unlikely to simply reflect changes required for generation of impaired movements, because it was not seen in feigners showing the same behavioural deficits. Rather, this P3 enhancement in patients may represent a neural biomarker of unconscious processes, including additional emotional loading, related to active suppression of brain circuits involved in the attribution of self-agency.
Case examples of hysterical coma and paralysis in two Ojibway patients are used to introduce a discussion of conversion symptoms. Somatoform disorders are described using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition; these are then applied to hysteria in the Native American patient. The authors discuss the cultural context of conversion symptoms in this population and describe guidelines for the provision of culturally sensitive therapy by the family physician.
hysteria; Native health; North American Indians; psychiatry
Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms.
Design: Follow up study.
Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders.
Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia).
Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist.
Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up.
Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.
Key messages Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists
Rediagnosing 103 ICD-9 Hysteria cases on DSM-III, the authors found Conversion Disorder and Atypical Dissociative Disorder to be the most common diagnosis. Somatization Disorder was diagnosed only in 8.7 per ant of cases. Twenty-nine per cent cases received double diagnoses. Limitations of using DSM-III on Hysteria patients are mentioned and a suggestion is made to include a new category of ‘Simple Dissociative Disorder’ in the DSM-III.
Conversion disorder (CD) is a psychiatric disorder, yet the diagnosis cannot be established without the expertise of a neurologist, as distinguishing a functional from an organic symptom relies on careful bedside examination. Joseph Babinski considered the absence of pronator drift as a ‘positive sign’ for hysterical paresis but the validity of this sign has never been evaluated. The aim of this study was to examine the sensitivity and specificity of the “drift without pronation” sign.
Twenty-six patients with unilateral functional upper limb paresis diagnosed with CD (DSM-IV) and a control group of 28 patients with an organic neurological condition were consecutively included. The arm stabilisation test was performed with arms stretched out in full supination, fingers adducted, eyes closed for 10 seconds. A positive “drift without pronation” sign was defined by the presence of a downward drift without pronation.
All CD subjects (100%) displayed a positive sign when only 7.1% of organic subjects did (Fisher’s p < 0.001). The sign yielded a sensitivity of 100% (95% CI:84%-100%) and a specificity of 93% (95% CI:76%-98%).
The observation of a “drift without pronation” sign is specific for Conversion Disorder and can be of help in making a quick distinction between organic and functional paresis at the bedside.
Conversion disorder; Pronator drift; Arm paresis; Functional symptom
The reorganization of the medical department of the Veterans Administration has given considerable impetus to neurology, a part of the division of psychiatry and neurology. The neurologic service of the V. A. is the largest in the world today, and is constantly increasing. This service is made available to veterans through hospitals and regional offices within the designated area, which are branch administrative offices under the central office.
A residency training program for specialization is under the direction of a deans' committee in every large medical center. This committee, which is formed from the faculties of medical schools, also approves the visiting medical staffs of hospitals. The neurologic program consists of a number of special activities, which include residency training for certification, neurologic diagnosis, rehabilitation of patients with chronic illness, electroencephalography, epilepsy, aphasia and research. The paraplegia program is now a separate service, but is also participated in by the neurologist. Both the neurologist and the psychiatrist are interested in the patient with organic psychosis, and the neurologist also works in close relationship with the neurosurgeon.
There is need for neurologists in the V. A., which offers attractive opportunities in clinical practice and in research, as well as inducements of advancement and adequate financial returns.
A case of Insulinoma is presented here because of the uncommon and peculiar clinical manifestation in the form of fits of unconsciousness with bizzare movements of limbs, which were considered to be due to Conversion Reaction and treated as such for a period of two years without any success. She recovered and was relieved of symptoms after surgery.
Hysteria and malingering, both commonly seen, especially in orthopaedic clinics, are reveiwed. Advances in psychology and psychiatry are often unknown or ignored by surgeons, who may thus mistreat or misdiagnose a multitude of conditions.