Conversion Disorder

What is conversion disorder?

Conversion disorder (also known as functional neurological system disorder) is a condition in which a person experiences physical and sensory problems, such as paralysis, numbness, blindness, deafness or seizures, with no underlying neurologic pathology. These problems are serious enough to negatively impact important life functions, such as academic performance, social relationships and family life.

Children with conversion disorder are not faking or intentionally producing their physical or sensory problems. They are real, but the problems are not caused by underlying medical problems; rather, they are impairments in the normal functioning of the body. Conversion disorder is often, but not always, driven by poorly expressed distress, for which relief is provided by the existence of the symptoms.

Causes

Conversion disorder is still a poorly understood diagnosis in children. The name “conversion disorder” refers to the conversion of emotional stress to physical symptoms. But these same kinds of physical and sensory problems can occur with or without known psychosocial or traumatic stressors.  Because of this, the broader term “functional neurological symptom disorder” is gaining acceptance for the condition. Diagnosis and treatment are essentially the same whether or not the problem has an identifiable emotional cause.

Conversion disorder is more typical in girls than in boys. It is more common in older children and in adolescents, than in pre-pubertal children. Most children with conversion disorder do not have a history of behavioral problems, and have low conflict with authority figures. They are frequently recognized by family and friends as being upbeat and “even-keeled.” It is common for children with conversion disorder to deny any current life stressors. Children with conversion are most often high achievers at school, and often participate in performance athletics (e.g., figure skating, gymnastics), or play on advanced competitive sports teams.

Signs and symptoms

Conversion disorder involves the loss of one or more bodily functions. Examples include:

  • Weakness or paralysis
  • Loss of balance or difficulty walking
  • Tremors or seizures
  • Vision problems, such as double vision or blindness
  • Hearing problems or deafness
  • Difficulty speaking or inability to speak
  • Difficulty swallowing

To be considered conversion disorder, one or more of these problems must be present and be serious enough to interfere with a child’s ability to function successfully — at school, in social interactions, or at home.

Testing and diagnosis

All of the problems that are signs of conversion disorder can, of course, have medical and neurological causes and can be signs of significant medical conditions. Although it is through medical examination that conversion disorder is diagnosed, there are frequently behavioral clues that conversion disorder is the appropriate diagnosis. For example, symptoms often begin with maximal intensity, occur only in certain settings or with certain people, and cause more withdrawal from typical activities than would be seen in children with similar neurologic or medical disorders.

Diagnosis generally begins with medical examination and testing by appropriate specialists, depending on the problems exhibited. These tests may include simple reflex checks, X-rays or other imaging, or an electroencephalogram (EEG) scan if the symptoms include seizures. This medical diagnosis must be done carefully, because the symptoms of conversion disorder can mimic those of other medical conditions. At the same time, a balance must be struck to avoid unwarranted invasive tests. In many cases, simple examination methods can be used to distinguish between problems with a neurological or medical basis from conversion symptoms.

If the medical and neurological examinations are consistent with a diagnosis of conversion disorder, the diagnostic team expands to include a mental health provider with expertise in working with children and adolescents. The mental health provider may help the family identify thinking patterns, stressors or events that may be associated with the symptoms. However, with many families, there is no identified underlying stressor, or the stressor(s) take some time to identify. In these cases, mental health treatment focuses on the young person’s thinking patterns around his or her symptoms, as well as maximizing the child’s return to full functioning.

Conversion disorder can sometimes occur in combination with other conditions, such as mood disorders, panic disorder, generalized anxiety disorder or post-traumatic stress disorder (PTSD). The psychological assessment will include a diagnosis of any other mental health issues that may need to be addressed in a treatment plan.

Treatment

Children and families who receive a diagnosis of conversion disorder can initially be confused about or resistant to the idea that the problems have no medical or neurologic cause, and therefore are not treated medically. It is critical that the medical team make it clear that the problems are real, quite distressing, and not “in the child’s head.” It is, likewise, important that the team emphasize that this condition is highly treatable. An explanation of the relationship between mind and body, and how the two interact, is often a helpful starting point. For some children and their families, this explanation will be enough to begin the process of recovery.

The hallmark of effective treatment for conversion disorder is emphasis on returning to age-appropriate functioning. This can begin with reinstitution of regular daily routines, and return to school and other activities. 

For young people with weakness, tremor or sensory loss, additional rehabilitative treatment may be needed. This may include:

  • Counseling — cognitive behavioral therapy or psychotherapy to address anxiety and thinking patterns about symptoms, as well as avoidance of any underlying stressors. Counseling may also be needed to address any co-occurring mental health conditions, such as depression or anxiety.
  • Physical or occupational therapy — to strengthen and loosen muscles that may have weakened and tightened through inactivity.
  • Medications — to supplement the counseling treatment for stress and anxiety and for any associated mental health conditions.

Outlook

For the majority of children, the symptoms of conversion disorder resolve within days to months. For most of these children, the symptoms will remit and never return. Early intervention, and return to regular activities is associated with the best outcomes.

Follow-up care

In some cases, the symptoms of conversion disorder will disappear quickly and no follow-up care will be required. In other cases, longer-term physical, occupational or psychotherapy may be required.

When conversion disorder is diagnosed with mental health conditions, regular psychotherapy follow-up is recommended.

Why choose CHOP?

Children’s Hospital of Philadelphia (CHOP) has a skilled team of child and adolescent mental health providers who work in collaboration with other medical specialists to diagnose and treat complex mind-body problems such as conversion disorder.

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