conversion disorder

1. CONVERSION DISORDER IN
CHILDREN :
A CRY FOR HELP
Presented By : Moderator:
Dr. Nishant Agarwal
PGT
Department of Pediatrics
GMCH

2. Introduction
 Physical (somatic) Symptoms are extremely common in
children and adolescents.
 Psychological distress may be expressed as somatic
symptoms.
 Medically unexplained symptoms refer to all bothersome or
recurrent bodily symptoms that do not have a recognized
medical illness explanation.
 May lead to distress, impairment in functioning and healthcare
seeking behaviour as in Somatoform or Somatic Symptom
Disorder.

3.  Conversion Disorder (CD) is a type of Somatoform
Disorder(DSM IV) or Somatic Symptom Disorder(DSM
V)characterized by a rather acute and temporary loss or
alteration in motor or sensory function that appear to stem its
root from psychological issues (conflict), produced
unconsciously by patient.
 Affected children and adolescents are often severely impaired
and at risk of serious long-term physical and psychosocial
complications, including educational failure, social isolation,
physical disability and psychiatric morbidity.
 Extensive use of paediatric and allied health resources .

4. HISTORY :
 Hysteria :Greeks , Ancient Egyptians
 Demonic Influences : Middle Age
 Freud and Breuer jointly reported the first case of hysterical conversion,
the case of Anna O(1880-1882). They theorized that symptoms of
hysteria represented unwanted emotional distress or conflict that was
suppressed and kept unconscious by the individual(defence mechanism),
only to appear in the form of medically unexplainable bodily symptoms.
Freud named this process “somatic compliance” or “conversion,” and
thus, with the case report of Anna O, both “conversion hysteria” and the
“talking cure” were born.
Photographs of women being
treated for hysteria by Charcot.

5.  In DSM-I (1951), hysteria became conversion reaction;
 In DSM-II (1968), hysterical neurosis, conversion type
 Finally, in DSM-III (1980), conversion disorder, the term that
remains to this date.
 DSM-V :Functional neurologic symptom Disorder
 ICD 10: Dissociative Disorder

6. ICD-10 VS DSM IV :

7. DSM-V:
 A. One or more symptoms or deficits affecting voluntary motor or
sensory function.
 B. Clinical findings provide evidence of incompatibility between the
symptom and recognized neurologic 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.
 Specify symptom type: weakness or paralysis, abnormal movements,
swallowing symptoms, speech symptom, attacks/ seizures, or
anesthesia/sensory loss, special sensory symptom (visual, olfactory, or
hearing), or mixed symptoms.

8.  Specify symptom type: weakness or paralysis, abnormal
movements, swallowing symptoms, speech symptom, attacks/
seizures, or anesthesia/sensory loss, special sensory symptom
(visual, olfactory, or hearing), or mixed symptoms.

9. Epidemiology :
 Some people have symptoms but not severe enough to warrant a diagnosis
 Estimated this occurs 1/3 of general population at some time or another
 Higher prevalence rates of conversion disorder are reported from pediatric
patients (16.7%) from child psychiatry in patients (0.5-10%)
 In West prevalence is very rare 3.6-13%
 In India prevalence rate is very high 31%
 This reflects more authoritative child rearing in India where free verbal
expression is discouraged leading to expression through bodily symptoms

10.  Rarely seen in children below 6 years
 Common in children between 10-15 years
 Relative equality of sex distribution in prepubertal children
 Relative incidents in females increasing in the ratio of 3:1 in early
adolescence
 Male preponderance or no differences in sex observed in Indian studies

11.  Rural areas
 Lower socioeconomic group
 Children from nuclear families
 Large size families of more than 4 members
 Immigrants
 Eldest or youngest sibling

12. Pathophysiology :
 Plato (fourth century BC) said. ‘This is the great error of our day, that
physicians separate the mind from the body.’

13. Splitting of the mind as a completely separate entity from the body is often
lamented in contemporary times
Start is attributed to the dualism of Descartes

14. Nowadays most paediatricians and child and adolescent psychiatrists
accept the need for a holistic approach, recognising that the physical
disorders described in paediatric texts have psychological dimensions, just
as the psychological disorders have physical dimensions

15. .
Biobehavioral continuum of disease

16.  Stress and anxiety can initiate and amplify somatic symptoms :

18. External Stressors :
 The role of precipitating factors have been reported in 65-85% of cases.
 Stressors include scolding by teachers or parents ,punitive attitude of
elders ,increased workload ,parental discord, financial difficulties,
rivalry ,academic difficulties, examination phobia , school avoidance,
impending marriage, death of parents and difficulty in accepting
religious practice .
 Unusual prolongation of symptoms after previous organic illness is also
known.
 Onset of symptoms after forced incestuous relationship especially in
adolescent girls is reported.

19.  Somatic symptoms can sometimes be a ‘mask’ :
 Distress occasioned by psychological or social factors can sometimes be
displaced onto a somatic symptom.
 Obtaining relief or sympathy in this way, by focusing on an ‘acceptable’
somatic symptom such as physical pain, may have the undesirable long-
term effect of training the child to somatise psychological distress in
future too

21.  Sensitive parenting can help children and adolescents learn to disclose
their psychological distress without needing to mask it with somatic
symptoms
 Psychological probing and psychologising of somatic symptoms can be
overdone.

23.  Health and illness can each be self-perpetuating :
 The great majority of ill children and adolescents want to get better
again in order to get back to their friends and resume normal activities.
 However, illness has its attractions too, including extra parental
attention, sympathy, gifts and relief from ordinary demands.
 Although health is usually more attractive than illness, the balance may
shift when the child or adolescent is exposed to acute or chronic life
stresses, particularly if the individual has no obvious escape other than
into illness. Intolerable but apparently inescapable situations can range
from undisclosed sexual abuse to being trapped as a high achiever who
is doing well at school but cannot sustain the pace or tolerate being
overtaken by others.

24.  Once the attractions of illness exceed those of health, any move to make
the individual better may provoke an intensification of symptoms.

25.  An accusatory stance is counterproductive :
 When children and adolescents first complain of a symptom, their
parents may be able to jolly them out of it or use a ‘come off it’ approach
with success. However, by the time their symptoms are being presented
to health professionals, the child or adolescent would lose face if they
got better in response to being told that they were putting it on, or
making a mountain out of a molehill, and parents would probably feel
foolish and angry too, for having been taken in. Predictably enough,
‘pull yourself together and stop wasting our time’ suggestions may lead
to persistence or worsening of symptoms as the individual demonstrates
that he or she really is ill.

26. Factors in the Child and Adolescents :
 Conscientious, obsessional, sensitive, insecure or anxious
 Temperamentally predisposed to withdraw from new situations, and
have sometimes had problems with peer relationships
 Only a minority have a co-existent psychiatric disorder

27. Factors in the Family :
 Learning theory describes ways in which physical symptoms to solve
psychological problems transmitted within a family
 Family members with somatic symptoms may provide models – in terms
of the symptoms themselves, and also in terms of coping style. If
relatives have stomach complaints, headaches or seizures, this may
sensitise children and adolescents to these problems or even provide
them with a model for conscious or unconscious imitation.
 Vicarious learning in a child who sees a sick sibling receiving extra
attention may lead to imitation of the sibling’s symptoms.

28.  If adults in the family typically respond anxiously to their own somatic
symptoms, assuming that something beyond their control is seriously
wrong, this may well foster anxiety, ‘pathologising’ attributions, and an
external locus of control in children and adolescents too.
 One over-involved parent, with the other distant;
 Parental disharmony;
 Parental overprotection;
 A rigid or disorganised set of rules rather than a stable and flexible set;
 Dysfunctional communication without conflict resolution.
 Favourable characteristics are said to include warmth, cohesion and
satisfactory adaptation to the realities of the family situation.

29. Etiology :
 In the 20th century ,thinking influenced by Freud’s psychoanalysis, It
was suggested that psychoanalytically repressed conflicts manifest or
convert to physical symptoms that represent an unconscious resolution
of the psychological conflict.
 The primary gain of the symptom converts an unacceptable unconscious
wish ,the defense against it and the punishment for it in body language.
Conversion symptoms also provide secondary gain by preventing the
patient from dealing with stressful situations ,by gratification of
dependency needs ,reducing demands on the patient to continue
functioning and mastering support ,solace and comfort along with
medical and family attention.

33. Learning Theory :
 Plato, John Locke, B.F.Skinner, Albert Bandura
 Classical Conditioning
 Operant Conditioning
 Social Learning

34. Learning Theory :
 Bobo Doll Experiment
 Bandura, Ross and Ross (1961) tested 36 boys and 36 girls from the
Stanford University Nursery School aged between 3 to 6 years old.
 A lab experiment was used, in which the independent variable (type of
model) was manipulated in three conditions:
 Aggressive model shown to 24 children
 Non-aggressive model shown to 24 children
 No model shown (control condition) - 24 children

36.  Children who observed the aggressive model made far more imitative
aggressive responses than those who were in the non-aggressive or
control groups.

37.  In the Family System Model ,three factors are believed to be necessary
for the development of conversion disorder :
 The child has a physiological disposition for or an existing organ
dysfunction
 The sick child and his/her illness enable the family to avoid conflict
 The family manifests four specific transactional patterns : enmeshment ,
overprotection, rigidity and lack of conflict resolution .

38.  Enmeshment is shown by excessive closeness such as lack of privacy
and blurring of interpersonal boundaries,
 Overprotection is evident when family members worry excessively
about each others health and safety . Overprotection may mean that the
child is prevented from engaging in age appropriate activities such as
sports or socials.
 Rigidity as a familial trait is manifested as a strong aversion to change
and trouble with transition points such as puberty.
 Excessive aversions to conflict results in much effort devoted to
avoiding points of disagreement. Consequently ,conflicts are never
resolved.

39.  Taylor (1986) articulated four key elements of childhood conversion
disorder:
 An intolerable predicament for which all solutions are blocked;
 A presence of an ally to promote sickness;
 An available model for sickness; and
 Possession of the necessary social skills.

40. Culture :
 In cultures that are less sophisticated regarding psychological and
emotional needs ,somatic symptoms are often presenting complaints for
underlying stress .
 Authoritarian and religiously fundamentalist cultures promote
conversion by fostering sexual repression and curtailing from thoughts
and feelings

41. Clinical Features :
 Irrespective of the specific neurological symptom, there are qualitative
features of the presenting complaint that tend to indicate a high
likelihood of CD.
 For instance, there may be biologically implausible aspects to the
symptoms, such as apparent generalized seizures with preserved
awareness and subsequent memory for the event, or there may be
weakness or sensory loss in a non-neuroanatomic distribution (often
delimited by a circumferential band halfway up a limb).
 There is often also an unusual time course to the symptoms. Common
patterns include either (i) chronic symptoms that began with a sudden
onset at maximal intensity and have remained present and undiminished
since onset, or (ii) paroxysmal symptoms that have occurred exclusively
in the presence of trusted family members or friends.

42.  Finally, and perhaps most important overall in identifying CD, the
impact of the neurologic symptoms on the patient’s life is typically out
of proportion to the apparent severity of the symptoms.
 Emotionally healthy children and teens who develop neurological
diseases (such as epilepsy, neuropathies, or movement disorders)
continue to attend school and participate in social activities, and
generally seek to maintain their previous level of involvement and
contact with their peers despite the presence of new neurologic
symptoms.

43.  By contrast, children and teens with CD usually withdraw from school
and/or other activities (especially performance-athletic activities, such as
dance, gymnastics, or figure skating).
 Past Medical History
 A parent experiencing chronic health problems with frequently
unexplained symptoms medically.
 Familiarity with medical terminology and/or the health care system; a
firm belief that the child’s symptoms are biological in nature

44. Symptoms :
 DSM IV lists four subtypes of conversion :
 With motor deficit or symptoms
 With sensory deficit or symptoms
 With seizures or convulsions
 With mixed presntations

45. Pseudoparalysis :
 The patient loses the use of half of his or her body or a single limb.
 The weakness not follow an anatomical pattern and is often inconsistent
upon repeat examination .
 The reflexes are normal .
 There are no fasciculations except in cases of long standing conversion.
 EMG findings are normal.
 Dropping the limp hand over the face in conversion misses the face.
 Hoover’s sign entails placing the examiner’s hand behind the ankle of
the paralyzed limb while the patient lifts up the normal leg. In
conversion paralysis pressure is felt under the paralyzed limb.

46.  Postural disturbances such as torticollis and kyphosis are seen.
 Atasia –abasia a gait disorder observed in conversion disorder is
characterized by a wildly ataxic staggering gait accompanied by gross
irregular jerky truncal movements and thrashing and waving arm
movements.
 Patients with this symptom rarely fall ,and if they do, they are generally
not injured.

47. Pseudosensory Symptoms :
 Patients with pseudosensory symptoms complain of numbness or lack of
sensation in various parts of the body.
 The loss of sensation typically follows the patient’s notion of their
anatomy rather than known characteristics of human nervous system
 Characteristic gloves and stocking anaesthesia and hemianesthesia
beginning precisely in the midline are reported.
 In children , hysterogenic zones such as joints and epigastric areas are
reported. The abdomen seems to be an area of predilection .The
distribution seems variable overtime.
 There is strong susceptibility to suggestions.

48. Pseudoseizures :
 These are the most difficult conversion symptoms to distinguish from
their organic equivalents.
 Betweeen 5-35% of patients with pseudoseizures also have epilepsy.
 In pseudoseizures body movements are nonstereotyped and
asynchronous as against tonic-clonic or both type of movements in true
seizures.
 Nocturnal seizures ,stereotyped aura ,cyanotic skin changes and postictal
confusion are uncommon in pseudoseizures.
 Tongue bites ,urinary or fecal incontinence and injuries after falling
occurs but are not very common.
 Pseudofits never occur in sleep and more likely to occur in presence of
people.

49.  Pseudoseizures may persist for 25-30 minutes .
 Pupillary and gag reflexes are retained and plantars are flexor after a
pseudoseizure.
 Serum prolactin and creatine phosphokinase are not elevated after
hysterical fits.
 EEG in pseudoseizures not show spike and waveforms or postictal
slowing.
 However ,variable interictal changes may confound the diagnosis in both
the cases.

50. Pseudocoma :
 Pseudocoma is difficult to diagnose.
 Because true coma may indicate a life threatening condition ,patients
must be given standard treatment for coma until diagnosis can be
established

51. Psychogenic Movement Disorders :
 Choreiform movements ,tics and jerks .These can mimic myoclonus ,
parkinsonism, dystonia, dyskinesia and tremor .
 These movements generally worsen when attention is called to them.
 Doctors sometime give patients with suspected movement disorders
placebo medication to determine whether movements are psychogenic or
a result of organic disorder

52. Pseudoblindness
 It is a common conversion symptom .
 Placing a mirror in front of the patient and tilting if from side to side can
be often used to determine pseudoblindness, because humans tend to
follow the reflection in their eyes

53. Pseudodiplopia :
 Seeing double can be found out by looking at patients eyes.

54. Pseudoptosis :
 Drooping of the upper eyelid is a common feature of myasthenia gravis .
 The diagnosis can be made on the basis of the eyebrow , in true ptosis
the eyebrows are lifted, in pseudoptosis , they are lowered.

55.  Pseudophonia and mutism :may be present .Patient’s cough and
whisper are normal. Throat examination reveals normal vocal cord
movements.
 Other associated dissociative symptoms ,e.g. loss of memory ,abdominal
or chest pain ,syncopal attacks ,hyperventilation of nonorganic origin as
a communication of psychological stress are common. Sleep and
appetite disturbances and constipation are common .

56.  Behavioural changes like nervousness aggressive overactivity
demanding tendencies ,temper tantrums ,crying have been described in
boys.
 Neurotic traits prior to hysteria like thumbsucking ,nail biting, enuresis
and shyness have been reported.
 Children with conversion often have comorbid anxiety and depression
while adolescents appear to be at risk for suicide.

57. Differential Diagnosis :True Physical Illness
 Multiple sclerosis, systemic lupus erythematosus and temporal lobe
epilepsy. Optic neuritis can be misdiagnosed as conversion blindness.
Periodic paralysis ,Guillain-Barre syndrome, myasthenia gravis
,polymyositis may present with vague muscular weakness. Spinal cord
tumors have often been labelled hysteria.

58.  Anecdotal reports of sex linked diffuse cortical sclerosis with Addison’s
disease ,congenital tertiary neurosyphilis ,subacute sclerosing
panencephalitis ,metachromatic leukodystrophy ,Friedrich’s ataxia with
dystonia musculum deformans exist.
 Tourette’s disorder should be considered in the differential diagnosis of
tics.
 Factors favoring a physical diagnosis include supportive findings in
physical examination and laboratory studies .

59. Depression :
 Depression can present with somatic complaints like headache,
weakness and tingling.
 Symptoms confirming depression include dysphoric mood, crying spells,
irritability, low self esteem, guilt, hopelessness, suicidal ideas ,poor
concentration ,lack of interest in usual activities , poor appetite or failure
to gain weight and sleep disturbances.

60. Psychosis :
 Although uncommon ,a physical symptom or somatic delusion can be
the presenting complaint for an adolescent with incipient psychosis.
 Findings of delusion , hallucinations, social withdrawal, differentiate
psychosis from conversion disorder.

61.  Hypochondriasis : Such patients experience but do not simulate their
symptoms.
 Factitious disorder and Malingering :Symptoms are intentional ,i.e.
voluntarily produced or feigned .Munchausen’s syndrome by proxy may
be present with vague symptoms in an apparently healthy child viewed
as sick by its parent.
 Pervasive Developmental Disorder : Autistic disorder or any other
disorder may present with concurrent physical symptoms
indistinguishable from conversion disorder . Developmental history
helps in differential diagnosis .

62. Approach to disclose the Diagnosis :
 The diagnosing physician must explain CD to the family, as effective
treatment is available and otherwise maladaptive coping may be
prolonged.
 With diagnosis comes the opportunity to evaluate for common
comorbidities, such as anxiety and mood disorders, as well as to avoid or
minimize sequelae, such as lengthy absences from school and potential
physical complications including contractures and osteopenia.
 A clearly stated diagnosis is the first step in returning the young person
to health. It can be useful to explain to the patient and family that CD is
a term for an illness that, while physically ‘real’ to the patient, is in fact
rooted in complex interactions between mind and body, and therefore
has psychological origins.

63.  Providing examples of biologic reactions to stress, such as sweaty
palms, shaky legs or flushed cheeks, can be helpful. These common
examples can help establish that, indeed, emotions do affect our physical
state.
 The key difference is that unlike the person who blushes speaking in
front of a crowd, the young person with CD typically is not consciously
aware of the triggering stressor.
 This is in fact a cardinal feature of the disorder, as the emotional
response is ‘converted’ into a physical symptom with the result that the
emotional trigger no longer ‘exists’ on a conscious level . Conveying
belief that the patient has subjectively ‘real’ symptoms, and that these
symptoms are not feigned or intentionally amplified, is pivotal in
building trust.

64. Approach to Management :
 Families may be better able to accept a psychosomatic approach to
assessment and treatment when their family doctor and paediatrician
have taken a holistic approach from the outset, considering the interplay
of biological and psychological factors from the first assessment
onwards.
 Involving mental health professionals is then just a change in emphasis
rather than a complete switch of direction that carries the implicit
message: ‘We have completed our investigations and there is nothing
really wrong with your child, so you had better see the psychiatrists
instead.

65.  The family need to hear from their doctor that the assessment so far has
ruled out the dreadful organic diseases that they were worried about
(tumours, ulcers, blockages, or whatever).
 This does not mean that the symptoms are unimportant; it simply means
that effective symptomatic treatments can now be deployed without
having to worry that there is something more sinister in the background.

66.  It can be useful to emphasise the value of ‘mind over matter’ and graded
rehabilitation approaches.
 It is often helpful to teach techniques such as ‘self-hypnosis’ or
relaxation therapy. These can make affected individuals (and their
parents) feel more in control of symptoms.
 This is treatment for the present episode and prophylactic medicine for
the future too.

67.  Children and adolescents who have a psychiatric disorder, such as
depression, in addition to their somatic symptoms, may need to have
their psychiatric disorder treated in its own right if it does not resolve as
a result of the other psychological interventions.

68. VEER (validate, educate, empathize,
rehabilitate) in the right direction :
 Validation is achieved through communicating that we, as the health
professional, believe the symptoms are ‘real’ to the patient, not feigned
or ‘faked’ and that at some level the symptoms and the diagnosis are
distressing.
 Educating the patient about the natural history of CD is an important
intervention. For the majority of paediatric patients, the symptoms often
subside and go away within weeks to a few months. The family and
patient need to be reassured that the medical professional will still be
available for follow-up and medical reassessment in the future

69.  Empathizing with families about the stigma of mental health issues and
problem solving with them about how they are going to explain the
illness to friends and family can also be very helpful
 Rehabilitation is the mainstay of management of paediatric CD. This
starts with the basics of getting back to a regular routine with respect to
eating, sleeping and exercise/activity. It is vitally important to enlist the
assistance of the parents and to have the young person start returning to
school and normal activities. The initial goals are very modest with
progression thereafter.
 A key role of parents and family is to actively distract their child from
the symptoms and focus instead on leisure activities that the young
person enjoys and that are developmentally appropriate.

70.  Cognitive behavioural therapy (CBT) is effective and a referral should
be provided.
 Involvement of a wider circle of health care professionals
(physiotherapy, occupational therapy, and speech and language therapy)
can be helpful depending on the symptoms, especially if all health care
providers are working towards a return to normal function.
 Psychiatric referral for assessment and treatment of protracted symptoms
or severe comorbidity is also recommended.

71. Prognosis :
 As high as 85-90 percent of patients are asymptomatic within 2-3 weeks
of inpatient treatment while 60-70 percent show recovery or marked
improvement on discharge.
 Associated with a good prognosis are a sudden onset ,short duration of
symptoms ,an easily identifiable stressor and good premorbid
adjustment.
 Pseudoseizure as a symptom particularly in females and comorbid
medical or psychiatric conditions have a poorer outcome.

72. References :
 Nelson Textbook of Pediatrics 20th Edition
 Recent Advances in Pediatrics –Pediatric Neurology by Suraj Gupte ,JAYPEE
 Child and Adolescent Psychiatry by Robert Goodman and Stephen Scott ,3rd Edition
,Wiley Blackwell
 A Clinical Approach to Pediatric Conversion Disorder by Catherine E. Krasnik
,Brandon Meaney, And Christina Grant
 International Association for Child and adolescent Psychiatry Textbook of Child and
Adolescent mental Health
 Caplan and Saddock’s Comprehensive Textbook on Psychiatry 9th edition
 Rutter’s Child Adolescent Psychiatry

73. Acknowledgements :
 Dr. Bornali Das
 Department of Psychiatry
 Dr. Bobby Hmar
 Assistant Professor
 Department of Psychiatry

74. Thank You

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Group 1 Group 2
Class 1 82 95
Class 2 76 88
Class 3 84 90

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