Review Conversion Motor Paralysis Disorder

Review

Conversion motor paralysis disorder: overview and rehabilitation model

RJ Heruti1,4, A Levy2,4, A Adunski3,4 and A Ohry*,1,4 1Rehabilitation Ward, Reuth Medical Center, Tel-Aviv, Israel; 2Shalvata Psychiatric Hospital, Hod-Hasharon, Israel; 3Geriatric Department, Sheba Medical Center, Tel-Hashomer, Israel; 4Sackler Faculty of Medicine, Tel-Aviv University, Israel

It is important to consider a dierential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD) ± `Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting oers the bene®ts of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic ®ndings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found. Spinal Cord (2002) 40, 327 ± 334. doi:10.1038/sj.sc.3101308

Keywords: conversion disorder; motor paralysis; rehabilitation model; interdisciplinary team approach; overview

Introduction Patients with physical impairment secondary to these patients often require comprehensive assessment, trauma, without evidence of organic etiology are treatment and rehabilitation. seldom referred to rehabilitation centers. On those Rehabilitation is an expensive and time-consuming occasions it is important to consider a dierential process involving a highly skilled multi-disciplined diagnosis between paralysis on an organic basis and team as well as a detailed and complete diagnostic paralysis and disability due to psychological mechan- follow-up.1±4 The inter-disciplinary team approach5 in isms. Management may be aected at several levels: a rehabilitation center oers distinct advantages in the treatment of conversion disorders (CD). CD is similar 1. Diagnostic (dierential diagnosis, ruling out or- to organic disabilities in that it aects the occupational ganic causes). and social aspects of the patient's life. In addition to 2. Treatment (psychiatric, psychological, rehabilita- the obvious bene®ts of a comprehensive approach, the tion, long-term follow-up). stigma of psychiatric hospitalization is avoided. 3. Administrative (determination of paralysis bene®t Initially, in many cases neither the patient nor the due to a conversion disorder may, or may not, be treating sta are aware of the conversive etiology. legally similar to other forms of paralysis, Patients suspected of malingering or having secondary depending upon the payer, or health care system). gain from their disability must be dierentiated from 4. Social and occupational issues. those with CD. We review recent as well as historically important Accurate diagnosis is imperative as erroneous medical literature concerning patients sustaining the diagnostic labeling may expose these patients to most dramatic type of CD ± motor symptoms, unnecessary treatments and the potential for serious weakness or paralysis for instance ± `Conversion Motor side eects. These in turn may have a long-term Paralysis'. These cases are relatively rare and there is no detrimental impact on medical management. Even precise epidemiological mapping of the prevalence and without an organic basis for their signs and symptoms incidence.2,4 The dierential diagnosis, pathophysiology, potential psychiatric co-morbidities, accompanying disabilities (mental and others), management and *Correspondence: A Ohry, PO Box 2342, Savyon 56530, Israel rehabilitation aspects are reviewed and discussed. Conversion paralysis RJ Heruti et al 328

Overview History itself has provided evidence of women with extra-ordinary achievements, all of them with hysteria, History of hysteria such as Theresa of Avila and Florence Nightingale.7 Hysteria was ®rst documented 4000 years ago by the There are reports of Mass Hysteria, mostly during Egyptians, who believed the symptoms originated wars or crisis.11 Of those with less favorable achieve- from the uterus, hence the name (hysterus).2 `Hyster- ments, Adolf Hitler can be mentioned, as suering ical' conditions included combinations of seizures, from hysterical blindness. paralysis, and anesthesia. During the 17th and 18th centuries a variety of disorders, such as: hypochon- driasis, hysteria, dyspepsia, `gas and spleen disease' De®nitions (Vapours) were included in the general term ± There are a variety of psychological disorders, which `Nervous Disorder', a term created by Briefe in may result in physical disability without any organic 1603, that was subsequently replaced with the vague basis. Confusion has arisen because of the multitude of term `Nervous Temperament'.6 The modern age of terms and de®nitions, as well as overlap between nerve pathologies commenced in 1843, the year Du historical and current terminology. While in the past Bois Reymond demonstrated electrical conduction in the term hysteria was used in multiple contexts, the nerves. No electrical disturbances were found in the following is the current accepted terminology:4 `Nervous Temperament', leading to the hypothesis of psychogenic origin.7 The term `Hysterical Conversion' (a) Somatization Disorder ± Classic historical hysteria was created about 100 years prior to Freud's birth, in (Briquet's syndrome) an attempt to justify the existence of hysteria as a (b) Hysterial Neurosis ± including: diagnosis. The French neurologists, Babinski and (1) Conversion Disorder (CD) Charcot were among the ®rst to publish articles (2) Dissociative Disorder concerning hysteria in the modern literature. Lher- (c) Anxiety Hysteria ± includes Freud's de®nition of mitte wrote `hysteria is the mother of deceit and phobia trickery'. Babinski removed from hysteria some (d) Hysterical Personality ± a term that was sub- components, such as; secondary physical ®ndings, stituted by the term Histrionic Personality. malingering, self-injuries and pathological lies. He de®ned hysteria as a disease with a psychological Most terms included in the above terminology are etiology, and no clear physiological or morphologic associated with the present term `Somatoform Dis- evidence, and characterized the hysterics as hyper- order'. The de®nitions used come from DSM-IV4 suggestible and easy to hypnotize.6,7 Paul Briquet was concerning a group of disorders, characterized by the ®rst to make an association between CD and somatic symptoms not adequately explained by a central nervous system disorders during the 19th disease, side eects of medication or due to any other century. He claimed CD was due to stress and psychological mechanism (ie Panic Disorder). The environmental situations, aecting `aective' areas in symptoms cause signi®cant distress, aecting dierent the brain of person with pre-morbid hypersensitivity.8 aspects of life (functional, social and occupational). His follower, Charcot, hypothesized that these patients Unlike Factitious Disorder or Malingering, the were suering from a global disorder of the brain, somatic symptoms are not deliberate (the patient has exposing them to the development of CD. He no voluntary control over their production). Similar developed the primary description of hysteria and psychological symptoms might accompany other contributed to the understanding, diagnosis and general diseases, but neither disease nor medical management of this disorder. Lately, his work has condition explain the somatic symptoms found in regained recognition, when the component of his patients suering from Somatoform Disorder. This theory concerning the pathophysiology of trauma group includes several conditions, each sharing the was introduced into the modern theories regarding absence of an organic disease as an etiology for the post-traumatic stress disorder (PTSD) and Somato- symptoms.4 form Disorder.9 The term Conversion Disorder (Hysterical Neurosis Freud, a student of Charcot, de®ned `La Grande ± Conversion type) is listed in the DSM-IV4 under Hysterie', that overlapped the de®nition of motor Somatoformic Disorder group (code 300.11), and is paralysis. Freud's concept of conversion originated described as a psychological disorder, characterized by from an integration of medical thoughts and knowl- somatic symptoms with no physiological abnormalities, edge in this area during the 19th century, which led but with an underlying psychological basis. Most of the him to create the term `Conversion Neurosis'. conversion symptoms (CS) are neurological and usually According to his traumatic model of hysteria, relate to the loco-motor system. The motor symptoms published in 1899, hysterical symptoms stem from include convulsions, paralysis, weakness, dyskinesia; sexual trauma, that activates an old traumatic event sensory symptoms include paraesthesia or anesthesia, (Nachtriglichkeit). Freud argued that through analysis blindness or speech disorders. These symptoms nor- the childhood trauma is restored and the neurotic mally suggest the existence of a neurological disorder or symptoms released via a transfer mechanism.10 other similar medical condition.

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The term Conversion State is used when there is an According to DSM-IV the risk factors include unconscious simulation of an organic disorder. When previous physical disability, exposure to other disabled it appears together with an organic disease, it is subjects and extreme psycho-social anxiety.4 There is regarded as functional overlay. limited information concerning a higher frequency of CD among relatives of subjects with CD. A higher frequency in monozygotic twins, but not among Pathophysiology dizygotic4 has, however, been reported. Ljundberg Several theories were constructed in order to explain was the ®rst to demonstrate higher rate of CS among the etiology of CD.2 By constructing the theory ®rst-class relatives of conversion subjects (12 ± 14 times regarding the existence and action of the unconscious, in females and 4 ± 6 in males), arguing for an hereditary and based on his experience with conversion patients, tendency, in addition to environmental causes.21 Freud has provided the understanding of the psycho- Usually CD appears in adolescence or young dynamic background and etiology of CD. Suppression adulthood. Presentation before the age of 10 or after is the major defense mechanism involved in conversion, 35 is rare, though rarely cases have been reported in as noted by the close relation between conversion the ninth decade.4 CD in children below the age of 10 conditions and traumatic events in the patient's past.12 is usually limited to walking impairments22 or According to Freud, an impulse or a wish, that cannot convulsions. be ful®lled due to negative connotations (such as, fear, shame, guilt or anger) is converted into physical expression, so that the CS actually re¯ects a symbolic Clinical presentation solution to the same unconscious psychological con- Subjects suering from CD might behave in a way ¯ict. Freud accentuated the symbolic relation existing known as `la belle indierence', a situation in which the between the type of the CS and the con¯ict.13,14 patient appears detached from the physical symptoms, Freud de®nes primary and secondary gains a patient that otherwise would have caused him great anxiety. receives: Primary gain ± anxiety produced by an Other presentations are the dramatic of histrionic. The internal unconscious defensive mechanism is converted intensity of the disability is usually to a level that into symbolic physical symptoms, while the con¯ict aects activities of daily living. CS is often aggravated remains limited within the unconscious, thus resulting by anxiety and tension states, such as the death of a in reduction of the anxiety level. relative or a war situation. Secondary gain ± achieved by avoiding certain During the course of the disease the subject tends to obligations or by getting support from being a patient dependant behavior or adopts `the patient role'. (ie, avoiding work or responsibility, getting care, Accompanying psychological symptoms are abundant attention etc). and include dissociative disorder, depression, and personality disorders (especially borderline anti-social and dependant).4 The symptoms are divided according Epidemiology to the dominant clinical presentation. The frequency of CD varies among dierent reports In this review CD with motor symptoms is the from 11/100 000 to 300/100 000 according to the major focus. Motor symptoms might include equili- population type.2,4 The annual incidence in Monroe brium or coordination impairment, weakness or county, New-York was 22/100 000 cases, compared to paralysis, vocal disorders (hoarseness to aphonia), 11/100 000 in Iceland during 1960 ± 1969.15 CD dysphagia or a choking sensation in the throat, and accounts for up to 1% ± 3% of patients in psychiatric urinary incontinence.4 CS does not usually follow outpatients clinics.16 Hafeiz described a frequency of known anatomical or physiological routes. It is 10% found in a sample patients taken 3 years,17 but characterized by inconsistency and instability of the there are reports of up to 20% among patients referred presence and severity of the signs and symptoms. to various evaluation procedures.18 Paralyzed limbs might move `accidentally' while There are divided opinions on the male-female performing activity or when attention is shifted.23,24 frequency of CD. It would appear to be more frequent Conversion Gait Disorder. This disorder consists of in females, with reports varying from 2 : 1 to 15 : 1,17,18 uni- or bilateral lower limb weakness, with possible although other reports state that there is no accompanying ataxia and/or tremor. The gait does not dierence.19 usually resemble any pathological gait of known CD was described as more frequent in rural areas, neurological origin, and is easily diagnosed by a among low socio-economic status, and among subjects clinician experienced in CD. According to Keane, with less medical and psychological knowledge.4 High who described 60 patients with conversion gait frequency of CD was found among Apalash men,20 disorder, dramatic recovery is a major sign directing and females in Sudan.17 Several modes of CD, such as towards a conversion origin. Dystonia and chorea are a fall accompanied by loss of consciousness, are the most common conversion symptoms among related to cultures, where CS expresses anxiety. Thus, children, and are more dicult to diagnose.23 Often it is important to evaluate the relation between the CS diagnosis is delayed, and may involve many unneces- and cultural context. sary diagnostic tests.22

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Limb Paralysis. Several reports concerning conver- regularly, and overlaps may occur between several sion limb paralysis have been found in the literature. disorders. Cardenas et al describe upper limb paralysis among The diagnosis is always temporary and conditional, chronic pain patients.25 Withrington reports ®ve due to the time factor involved until the appearance of women, suering limb weakness without accompany- organic evidence (as in systemic disease). Of impor- ing muscle atrophy.26 tance is the fact that between 25 and 50% of patients Other forms of conversion motor disorders de- diagnosed as conversion, will subsequently be diag- scribed in addition to those mentioned above, include nosed with an organic medical condition.33,34 This vocal disorders (hoarseness, dysphasia, aphonia, etc),27 percentage is lower in recent publications, most bronchospasm (characterized by recurrent stridor probably because of increased awareness to the attacks in youth, accompanied by panic reaction),28 disorder, concurrent with advances in diagnostic and motor visual disorders (very rare, and expressed techniques. The possibility that a present symptom is as blepharospasm).29 conversion increases, if the patient has a history of un- Other sub-groups of CD include sensory loss or explained physical complaints (especially conversion) signs such as anesthesia, paresthesia, visual impair- or dissociative symptoms, and if he/she meets the ment (mainly amblyopia),29 blindness, deafness, hallu- criteria for Somatization Disorder.35 The less the cinations,30±31 sleep disorders,32 etc. The symptoms patient's medical knowledge, the more he/she appears can `travel' between systems, for example, vocal with inexplicable and irregular symptoms. In contrast, disorder `recovers' and is replaced by pathological symptoms of educated patients are very similar to gait. genuine ones.3 Despite all the above, the diagnosis is frequently clinical, based on history and physical examina- Diagnosis tion.3,24,36 The diagnosis is determined after ruling out organic History ± Supporting indicators in the patient's components or other psychogenic diagnosis.1 The history include: previous functional disorders, role diagnostic process consists of precise medical history, models among family member or friends, secondary thorough physical examination and the use of appro- gain, professional relation to medicine (in Baker's priate diagnostic tools. series 5/26 women were nurses),24 previous psychiatric The diagnostic criteria according to DSM-IV to background, and self-discharge from hospital. The determine CD are:4 onset is usually acute and sudden, though there may be a gradual form.20 . One or more symptoms or de®cits aecting Other details in the patient's history compliant to a voluntary motor or sensory function that suggest diagnosis of CD include mental retardation, concur- a neurological or other general medical condition. rent psychiatric disease, physical or psychological . Psychological factors judged to be associated with trauma in childhood or close to the presentation of symptoms or de®cit because the initiation or CS, and family history of physical disability.4 exacerbation of the symptoms or de®cit is preceded Physical examination ± The signs leading towards a by con¯icts or other stresses. non-organic diagnosis include inconsistent ®ndings, no . The symptom or de®cit is not intentionally adjustment between physical and functional ®ndings, produced or feigned (as in Factitious Disorder or and inconsistency between the symptoms and anato- Malingering). mical or physiological systems.20 Objective signs, such . The symptoms or de®cit cannot, after appropriate as pathological deep tendon re¯exes are rare. Signs investigation, be fully explained by a general seen more frequently are imitation of real symptoms medical condition, or by the direct aects of a from observation (eg, of convulsions of another substance, or as a culturally sanctioned behavior or patient). CS will rarely lead to physical changes or experience. disability, so pressure sores, contractures or muscle . The symptom or de®cit causes clinically signi®cant atrophy are rare. Dysphagia will be similar for both distress or impairment in social, occupational, or solids and liquids.2,20,37 other important areas of functioning or warrants In order to reach a correct diagnosis a thorough medical evaluation. neurological examination is essential. Prominent . The symptom or de®cit is not limited to pain or suspicious symptoms include: jerky sharp movements, sexual dysfunction, does not occur exclusively unexplained tremor, inconsistency in ®ndings (eg, during the course of Somatization Disorder, and muscle strength of quadriceps in standing compared is not better accounted for by another mental to sitting), bizarre gait pattern, slow motion move- disorder. ments, over¯ow of emotion during the exam (painful expression, tooth grinding, breath holding, etc).38 The usual symptoms are motor and/or sensory Other signs include normal muscle tone, normal losses (`pseudo-neurological' symptoms), but convul- re¯exes, ¯exor plantar re¯exes, bizarre movements, sive and mixed presentation also exist. It should, and simultaneous contraction of agonist and antago- however be remembered that DSM-IV is updated nist muscles (if the patient is asked to ¯ex the elbow,

Spinal Cord Conversion paralysis RJ Heruti et al 331 contraction of the triceps, preventing ¯exion, is report with other sources (such as, friends, team noticed.23,24 When the examiner attempts to change members, etc). As mentioned above, signs that are an abnormal limb position, a resistance in direct limited to pain or sexual dysfunction are diagnosed as relation to the power exerted is felt.20,37 If a somatoform pain disorder or sexual dysfunction `paralyzed' arm is raised above the subject's head respectively, and not as CD.4 and released, it will not fall directly on his head, but to Voluntary behavior ± In order to dierentiate the side. between factitious disorder and malingering it is The sensory examination might reveal changes not important to assess the patient's awareness, the related to anatomical dermatomes, inconsistency in intention of the CS and their motivation.4 repeated examinations, misleading proprioception. Factitious disorder is suspected when there is a Conversion anesthesia in a hand or foot will have a partial combination of the following: dramatic and shape of a glove or sock, aecting all types of unfamiliar behavior, symptoms and behavior appear sensation, with no determinant level, and with a sharp and are aggravated in the presence of a team member, border, and not according to dermatomal levels.20,37 pseudologia fantastica rebellious behavior (opposing The autonomic system is usually unaected with full procedures, arguing with sta, etc), great knowledge in sphincter control and normal bowel movement. No medical terminology and routines, drug or alcohol spinal shock or other typical autonomic signs (eg, low abuse, evidence of many previous hospitalizations, pulse and blood pressure, dyspnea) are presented in small amount of visitors, and ¯uctuating clinical conversion tetraplegia.37 course, accompanied by aggravation of symptoms Additional examinations ± There are no pathologi- when primary evaluation is negative. Often it may be cal ®ndings in laboratory tests, supporting CD. On the dicult to dierentiate between factitious and conver- other hand, however, pathological ®ndings will not sion disorders.39 necessarily rule out CD.37 Factitious disorder is characterized by physical or Additional tests, ie, imaging (X-ray, CT, MRI) and mental symptoms produced voluntarily by the patient, electrophysiological studies (electroencephalography, while the unconscious motive is accepting the patient sensory and motor evoked potentials, urodynamics) role. There is no evidence of external incentive (ie, are usually normal, however, presence of ®ndings compensation, avoiding legal responsibility). Proving a rarely elucidate the clinical symptoms. When a subject certain symptom is voluntarily counterfeit is made is admitted with paraplegia, normal re¯exes and full through direct evidence, whilst ruling out organic control of sphincters, a routine X-ray is sucient, and etiology.4 The symptoms most likely include forgery of the diagnosis is clinical. CT and MRI are unnecessary, complaints (abdominal pain, in the absence of pain), and are performed just as additional supporting self-in¯iction (ie, injecting infectious substance in order evidence for the clinical diagnosis.23,36 to cause abscess), aggravating symptoms of presenting disease (false and exaggerated convulsions in an epileptic subject) or combination of the above. There Dierential diagnosis are two forms: (a) Munchausen syndrome ± chronic According to Lazare the classic characteristics of CD, with physical signs. (b) Ganser syndrome ± character- such as symbolization of the symptoms, secondary ized by mental symptoms, often psychotic, that are not gains, histrionic personality, `La Belle Indierence', are directed toward a familiar disorder.39 There is great of no diagnostic power and are unnecessary.12 On the variability in the nature of the symptoms, they do not other hand, symptoms considered as conversion, such respond to treatment, and are aggravated when the as sensory loss with no anatomical pattern, suggest- patient notices that he is being observed. The patient ibility, etc may accompany diseases of the nervous presents his suering dramatically, but in an incon- system.34 sistent manner and embedded with lies (Pseudologia Considering the dierential diagnosis of CD there Fantastica). Usually he has wide medical knowledge. are two major groups:4,33 When the primary evaluation is negative, new Organic background ± A thorough evaluation in symptoms will appear. When the true nature of the order to rule out organic etiology must be performed, illness is revealed (ie, direct evidence of self-in¯iction, before determining a diagnosis of psychogenic origin. identifying recurrent admissions etc), the patient will Potential general medical conditions (eg, multiple deny all proofs and will discharge himself hastily, sclerosis, myasthenia gravis, idiopathic dystonias) must against the physician's opinion, and will probably be carefully excluded.1,4,34 hospitalize himself in a dierent hospital. Often the Psychological background ± Two main sub-groups course is chronic with an onset at young age.4,39 can be noted in this group ie, voluntary and With malingering, the motive for producing the involuntary behavior. The decision whether a certain symptoms is conscious, and the purpose is prominent symptom is voluntary (factitious, malingering) or not, with clear secondary gain (eg, compensation, vacation is dicult and is usually reached only after a thorough from the army, release from the jail, etc) The patient evaluation relating the context of the symptom has a clear external motive, in contrast to the presentation, especially in the presence of some factitious patient, who is motivated by the mental primary gain.1 It is useful to crosscheck the patient's unconscious need to take on the patient role and

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receive treatment. Factitious re¯ects pathophysiology, or at least not bring the desired focus of attention. A whilst malingering re¯ects adjustment to certain focus on the positive not the negative should be condition (capture, jail). encouraged, and this may be achieved by the use of Involuntary behaviour ± The dierential diagnosis of `achievement charts' carefully screened obtainable involuntary CS include depression, Panic Attack,40 goals, videotape feedback, in order to demonstrate PTSD,41,42 Dissociative Disorder,4 and Borderline the progress.26,50 It is preferable to treat the patient in Personality.35 a quiet place, away from the main treatment area, in order to avoid acquired behavior.51 Treatment using this approach begins even during Treatment and rehabilitation the initial assessment when a diagnosis of CD is In the past, patients were referred to psychiatric suspected due to the anomalies discovered on physical departments, but this trend was changed, and due to assessment. The diagnosis given should be vague the functional loss patients are referred to rehabilitation rather than confrontational, ie in the case of hysterical wards.43 ± 45 The majority of papers on the topic are paralysis `spinal cord concussion', allowing the patient retrospective studies or case reports, authored by to undergo `a speedy recovery'.48±49 psychiatrists or specialists in physical medicine and Communication within the inter disciplinary team is rehabilitation. There are no long-term follow-up essential and regular team meetings to document the studies. The reference to treatment is minimal, contra- progress of the patient should be held. Any dierences dicting and vague, oering autosuggestion, placebo, and of opinion between team members must be discussed hypnosis as the main treatments of choice. When the only during these meetings.48 A case manager, possibly psychological intervention fails, inter-disciplinary reha- the psychologist, must direct and coordinate all bilitation treatment becomes even more of an impera- treatments. tive.5 It is our impression that treatment should be directed towards the symptoms and as such the patients The psychotherapeutics approach The object of this should be hospitalized in the correct units according to approach is to resolve the con¯ict which has led to the their physical symptoms, ie paraplegic or tetraplegic clinical picture of CD. Psychotherapeutic treatment is patients in a rehabilitation spinal unit, hemiplegic given on an individual basis and its success will patients in a rehabilitation stroke unit etc and not depend, to a large extent, on the cooperation of the placed in psychiatric units from the oset. Treatment in patient. Drug therapy in the form of Thiopentone has a rehabilitation system will also address the prevention proven itself to be an eective tool.52 Others report of secondary disabilities. Those disabled due to success with auto-suggestive treatments and hypnosis.53 conversion have many similarities to those with an organic basis for the disability, with regard to eects on The physical approach It is useful to combine the physiology, social and occupational consequences. above approaches with a physical therapy ap- Rehabilitation treatment should be introduced as proach.17,54 ± 55 Exercises as per the `vague diagnosis' early as possible.26 There is the need to rule out may be prescribed together with functional electrical neurological, orthopedic and other potential medical stimulation (FES),55 evoked potentials56 and biofeed- etiologies. The patients must be screened and diag- back techniques.16 It is essential that regular objective nosed, and to exclude those with suspected factitious measures be taken of the patient's functional abilities disorder, malingering, or where there is secondary and these will have a great impact on the recovery gain. Team members should be educated concerning outcome of the patient. Other objective measures in the the unconscious origin of the CS and the type of form of balance testing or gait analysis are also approach to be used in the treatment.43 The preferred important, since the results shown by the patient can setting is hospitalization in a rehabilitation ward in be compared to the normative data available. As stated order to observe the patients in all activities.26,44 ± 46 earlier the most successful approach to treatment When both the medical etiologies and the conscious would seem to be a combination of these three psychological etiologies are excluded, we are left with approaches. those patients disabled due to conversion disorders (impaired vision, balance de®cits, diculty in walking, limb paralysis, etc). Prognosis Three main treatment approaches should be con- Various reports on the prognosis of patients with CD sidered: are available.26,55 Some report hospitalization for weeks, and others months and yet others on The behavior modi®cation approach2,47,48 The objec- spontaneous recovery within 2 weeks, without any tives underlying this approach are a reduction in the treatment intervention.4,50,57 It should be stated, unwanted behaviors and a strengthening of the more however, that the longer the time to recovery, the less desired behaviors. In order to achieve these objectives complete will be the recovery.17 Reports have shown it is important to reward the more desired beha- that between 15% and 75% of CD patients demon- viors.47 ± 49 Rather than punishing the unwanted strate organic signs within 5 years of diagnosis due to behaviors they should, as much as possible, be ignored failure to recover or recurrence.17,20,50,51,53

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Factors indicating favorable prognosis include 10 Makari GJ. Dora's hysteria and the maturation of sudden onset, presence of stressogenic factor during Sigmund Freud's transference theory: a new historical onset, short duration between diagnosis and onset of interpretation. J Am Psychoanal Assoc 1997; 45: 1061 ± treatment,49 high level of intelligence,2 absence of 1096. de®nite psychiatric disorder,2,17 and aphonia and 11 Small GW, Propper MW, Randolph ET, Eth S. Mass hysteria among student performers: social relationship as blindness as presenting CS. Poorer prognosis is related 17 a symptom predictor. Am J Psychiatry 1991; 148: 1200 ± to severe disabilities with long duration, age above 1205. 50 40 years, and convulsions and paralysis as presenting 12 Lazare A. Current concepts in psychiatry: conversion CS.58 symptoms. N Engl J Med 1981; 305: 745 ± 748. 13 Miller E. Hysteria: its nature and explanation. Br J Clin Psychol 1987; 26: 163 ± 173. Summary 14 Yarom N. A matrix of hysteria. Int J Psychoanal 1997; When there is an apparent discrepancy between 78: 1119 ± 1134. objective ®ndings and clinical presentation, it is 15 Stefansson JG, Messina JA, Meyerowitz S. Hysterical important to consider the possibility of disability due neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand 1976; 53: 119 ± 138. to a psychological mechanism, at the earliest contact. 16 Fishbain DA, Goldberg M, Khalil TM, Asfour SS, Inaccurate diagnostic labeling may expose patients to Abdel-Moty E, Meagher BR, et al. The utility of unnecessary treatments with the potential for signi®- electro-myographic biofeedback in the treatment of cant side eects. This in turn will have a long term conversion paralysis. Am J Psychiatry 1988; 145: 1572 ± detrimental impact on medical management. 1575. The inter-disciplinary in-patient team management 17 Hafeiz HB. Hysterical conversion: a prognostic study. Br approach in a rehabilitation setting oers the bene®ts JPsychiatry1980; 136: 548 ± 551. of a comprehensive assessment and treatment for 18 Ziegler FJ. Hysterical conversion reactions. Postgrad patients with conversion motor paralysis. It is Med 1970; 47: 174 ± 178. important to note that this diagnosis is temporary 19 Chodo P. The diagnosis of hysteria: an overview. Am J Psychiatry 1974; 131: 1073 ± 1078. and conditional, since there may be a long delay until 20 Weintraub MI. Hysterical conversion reactions ± a the appearance of organic ®ndings (as in a systemic clinical guide to diagnosis and treatment. New York: disease). A complete medical assessment is essential in SP Medical, 1983. order to rule out any possibility of an organic etiology. 21 Ljundberg L. Hysteria: Clinical, prognostic and genetic In as many as 25% to 50% of patients diagnosed as study. Acta Psychiatr Scand 1957; 32: 1 ± 162. conversion, an organic medical diagnosis was found. 22 Thompson APJ, Sills JA. Diagnosis of functional illness presenting with gait disorder. Arch Phys Med Rehabil 1988; 63: 148 ± 152. References 23 Keane JR. Hysterical gait disorders: 60 cases. Neurology 1989; 39: 586 ± 589. 1 Parobek VM. Distinguishing conversion disorder from 24 Baker JH, Silver JR. Hysterical paraplegia. JNeurol neurologic impairment. J Neurosci Nurs 1997; 29: 128 ± Neurosurg Psychiatry 1987; 50: 375 ± 382. 134. 25 Cardenas DD, Larson J, Egan KJ. Hysterical paralysis in 2 Ford CV, Folks DG. Conversion disorders: an overview. the upper extremity of chronic pain patients. Arch Phys Psychosomatics 1985; 26: 371 ± 383. Med Rehabil 1986; 67: 190 ± 193. 3 Binzer M, Andersen PM, Kullgren G. Clinical character- 26 Withrington RH, Wynn-Perry CB. Rehabilitation of istics of patients with motor disability due to conversion conversion paralysis. J Bone Joint Surg 1985; 67: 635 ± disorder: a prospective control group study. JNeurol 637. Neurosurg Psychiatry 1997; 63: 83 ± 88. 27 Matas M. Psychogenic voice disorders: literature review 4 American Psychiatric Association: Diagnostic and Sta- and case report. Can J Psychiatry 1991; 36: 363 ± 365. tistical Manual of Mental Disorder, Fourth Edition. 28 Ophir D, Katz Y, Tavori I, Aladjem M. Functional upper Washington DC, American Psychiatric Association, airway obstruction in adolescents. Arch Otolaryngol 1994. Head Neck Surg 1990; 116: 1208 ± 1209. 5 Heruti RJ, Ohry A. The Rehabilitation Team ± A 29 Weller M, Wiedemann P. Hysterical symptoms in Commentary. Am J Phys Med Rehabil 1995; 74: 466 ± ophthalmology. Doc Ophthalmol 1989; 73: 1 ± 33. 468. 30 Sirota P, Spivac B, Meshulam B. Conversive hallucina- 6 Hare E. The history of `nervous disorders' from 1600 to tions. Br J Psychiatry 1987; 151: 844 ± 846. 1840, and a comparison with modern views. Br J 31 Nakaya M. True auditory hallucinations as a conversion Psychiatry 1991; 159: 37 ± 45. symptom. Psychopathology 1995; 28: 214 ± 219. 7 Mace CJ. Hysterical conversion. 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