Spinal Cord (2002) 40, 327 ± 334 ã 2002 International Spinal Cord Society All rights reserved 1362 ± 4393/02 $25.00 www.nature.com/sc 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, pathophysiol- ogy, 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