J R Soc Med 2003;96:436-438
doi:10.1258/jrsm.96.9.436
© 2003 Royal Society of Medicine
Conversion disorder in childhood—diagnosed too late, investigated too much?
P M Leary MD FCP(SA)
Bristol Royal Hospital for Children, Bristol, UK
Correspondence to: Professor P M Leary, Institute of Child Health, Directorate
of Children's Services, 6th Floor, UBHT Education Centre, Upper Maudlin
Street, Bristol BS2 8AE, UK E-mail:
mickleary{at}blueyonder.co.uk
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INTRODUCTION
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Conversion disorder is defined in the
Diagnostic and Statistical Manual
of Mental Disorders
(DSM-IV)1 as a
condition in which
symptoms and deficits in voluntary motor function suggest a
neurological
or other physical condition which is in fact not present. Child
psychiatrists
have reported a prevalence of 1–3% in the patients they
see.
2,3
Among
new outpatients at a paediatric neurology unit in the west of
England
the prevalence is closer to 10%. These cases place considerable
demands on
consulting time and diagnostic resources. In this
paper a case is made for
early recognition and for management
by the general paediatric team.
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ILLUSTRATIVE HISTORIES
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Case 1
A boy of 12 was referred for investigation of gait disorder.
There was a
five-month history of nausea, weakness, inverted
sleeping pattern and
inability to extend the right elbow. He
had not attended school since the
onset of his illness and had
undergone extensive investigation at a district
general hospital.
He was noted to walk with a bizarre staggering gait which on
close
inspection could be seen to be carefully coordinated. His right
elbow
was rendered unmoveable by sustained palpable contraction
of both biceps and
triceps muscles. Systematic detailed clinical
examination showed no
neurological abnormality. A tentative
diagnosis of conversion disorder was
made and the boy's background
was explored. He had experienced scholastic
difficulties at
primary school. Shortly before the onset of his illness he had
moved
with his peer group to a secondary school with high academic
expectations
of pupils. He had not been able to achieve these and the teacher
of
his favourite subject had humiliated him by rejecting class
work he had
done and throwing his workbook on the floor. Transfer
to another school was
unacceptable, as he did not wish to be
separated from his friends.
Psychotherapy was instituted with
gradual improvement. However, ten months
elapsed before he was
confident and well enough to return to school.
Case 2
This boy was referred at age 10 as a case of juvenile myasthenia gravis.
For five weeks he had been unable to open his eyes and the consequent
'blindness' had stopped him attending school. On examination it was
immediately evident that his eyes were being held firmly closed, to the extent
that they could not be prised open to inspect the cornea and conjunctiva. On
detailed physical examination no other abnormality was found. In the hospital
ward it was noted that he did not walk into furniture and, left alone, would
follow football matches on the television screen. Discussion with his mother
revealed that there were scholastic difficulties. He was the local village
football star and had been selected for a junior football academy. After a
trial period at this institution he had been rejected as not good enough.
Shortly after this setback he had been blamed for his team's defeat in a
needle match and from that day he had been unable to open his eyes. In
hospital he was provided with a pair of dark glasses which permitted eye
opening without loss of face in front of his peers. He was medically boarded
from playing football for the rest of the season. An approach was made to his
school headteacher and extra tuition was arranged in his weaker subjects.
Within two weeks, eye-opening had become normal and he had returned to full
active life.
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CLINICAL PROFILE
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During childhood, conversion disorder occurs most commonly in
the
10–15 year age bracket and the condition is roughly
twice as common in
girls as it is in
boys.
4 In most cases
symptoms
date from a minor illness or injury. Rigid obsessional personality
trait,
5 an anxiety
state or depression
6
and previous sexual
abuse
7 all
predispose
to development of a conversion disorder. Environmental factors
include
domestic stress, feelings of parental rejection, poor intrafamilial
communication,
unresolved
grief
8 and
unhappiness at
school.
9 Illness and
disability
can be amplified and prolonged when the patient has an ally
who
champions the notion that symptoms are due to organic
disease.
10 An ally
of this nature may be a family member or a healthcare
professional.
Symptoms are most commonly motor—paralysis, gait disturbance,
incoordination, tremor, loss of speech. Sensory manifestations include
paraesthesia, intractable pain, tunnel vision and blindness. Incapacitating
headache, unremitting fatigue and pseudoseizures are other common presenting
features. Allowance must be made for cultural variation in the mode of
presentation. A study in
Pakistan11 showed
'unresponsiveness' as the commonest presenting feature in conversion
disorder, and in certain areas of Southern Africa a state of apparent agitated
dementia is well recognized.
In the great majority of cases early diagnosis can be achieved by detailed
physical examination and the identification of incongruities. Reciprocal
contraction is palpable during attempts to use apparently paralysed muscle
groups and normal tendon reflexes can be elicited in the face of flaccidity.
Abnormal gaits are bizarre and do not conform to those seen in children with
diplegia, athetoid cerebral palsy, cerebellar dysfunction or hip disorder.
Sensory loss does not conform to dermatome or glove-and-stocking distribution.
Diplopia is present in all directions and may persist despite occlusion of one
eye. In apparent blindness, collisions and injuries do not occur. Short-lived
remissions may be noted when the patient is alone and when sudden
'emergencies' arise such as need for the toilet or for sustenance.
Pseudoseizures occur only in the waking state and in company. They may be
longlasting and commonly include repetitive pelvic thrusting movements which
are never seen in true seizures. Urinary incontinence is not a feature.
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NEUROPSYCHOLOGICAL MECHANISMS
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The results of some recent neurobiological studies are of note.
In a
controlled study, Roelofs
et
al.12 reported
that adults
with conversion disorders had abnormally long motor reaction
times
but normal duration motor responses. This is the reverse
of what is found in
organic motor disorder and implies impairment
in motor task initiation.
Imaging techniques have been used
to identify the areas of brain involved.
With positron emission
tomography in a patient with longstanding conversion
disorder
(leg paralysis), Marshall
et
al.13 noted
activation of two distinct
areas of prefrontal cortex; and Halligan
et
al.,
14 in a
man
with hypnotically induced paralysis of the left leg, observed
selective
activation in the same areas when the individual attempted
to move his leg.
Electrophysiological studies indicate that
these parts of the brain—the
right orbitofrontal and anterior
cingulate areas—are involved in motor
inhibition. Conversion
disorders and hypnotic paralysis may have
neurophysiological
mechanisms in common. Using single photon emission
computerized
tomography in seven individuals with unilateral sensorimotor
conversion
disorder Vuilleumier
et
al.15 found
consistent decreases in
regional blood flows in the contralateral thalamus and
basal
ganglia.
These changes were no longer evident after recovery. The findings in this
study suggest that in conversion disorder there is a transitory functional
disorder in striatothalamocortical circuits, which control sensory and
voluntary motor function.
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MANAGEMENT
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Fear of misdiagnosis with consequent litigation can delay the
positive
diagnosis of conversion disorder. Such anxiety can
lead to gross
overinvestigation and 'medicalization' of the
disorder with delay in
instituting effective treatment. Refusal
by parents to accept the absence of
organic disease may be another
major stumbling-block to effective management.
Such refusal
often goes with denial of any domestic tensions or disharmony
and
with anger directed at medical personnel—attitudes
that can greatly
hamper the institution of appropriate therapy,
as can misguided support for
any opposition to treatment expressed
by the patient.
Intervention begins with an acknowledgement that the young person has a
real illness which has seriously disrupted normal patterns of living. The
presenting disability should be regarded as a symptom reflecting unconscious
conflict. Wherever possible the child should be admitted to hospital,
preferably with some limitations on parental access. This may prove difficult
in view of current ward practice but it can often be achieved by reference to
the child's age and normal level of independence and by firm reassurance that
the nature of the illness does not justify a 24-hour parental bedside vigil.
In many instances this will serve to remove the patient from the conflict that
led to the illness and will also lessen the effects of parental lack of
cooperation if this is an issue. Special investigations should be limited to
the minimum compatible with exclusion of organic disorder. The patient's
primary gain from the illness should be identified at an early
stage—e.g. release from a stressful school situation. The therapeutic
programme should be tailored to allow the individual to recover without loss
of face in front of peers and family. It should be instituted without
delay.
Therapeutic success can be achieved through several different approaches.
Probably the most effective is a graded physiotherapy programme linked to a
reward system and directed by an empathic physiotherapist, as reported by
Bragier and
Venning.16 This can
be provided within the setting of children's hospital wards under the
supervision of general paediatricians. If the regimen is started early in the
illness, recovery can be achieved in most cases without recourse to the
overburdened child psychiatry and psychology services. Good results have also
been achieved with behaviour therapy (both positive and negative
reinforcement17),
psychotherapy,18
psychoanalysis19
and
hypnosis,20,21
but these are time-consuming and call for special training. They should be
reserved for complex cases that prove unresponsive to short-term admission and
graded physiotherapy. When depression and or anxiety are prominent features,
antidepressant and/or anxiolytic medication should be prescribed.
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PROGNOSIS
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Follow-up studies indicate eventual full recovery in from 85%
to 97% of
children. With early recognition of the nature of
the condition and prompt
intervention, some recover within a
few weeks or even
days.
22,23
In Turgay's study
23
only 3 out
of 89 patients took longer than four weeks to recover. Favourable
prognostic
features are recent onset of symptoms, monosymptomatic
manifestation
and a good premorbid
personality.
22 The
outlook is less good
when symptoms have been present for a long time before
institution
of appropriate
therapy,
24 when
conduct disorder has preceded
the
illness,
22 when
there is a history of sexual abuse, when
symptoms are
multiple
25 and when
an anxiety state or clinical
depression is present.
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CONCLUSION
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Every general paediatrician will see cases of conversion disorder,
and
successful outcomes depend greatly on early recognition.
Investigations should
be limited to the minimum compatible with
exclusion of organic disease, since
exhaustive investigation
will medicalize the problem in the eyes of parents
and patient
and can delay appropriate treatment. Admission to hospital is
usually
effective if the child is thus exposed to a positive therapeutic
programme
directed by an experienced physiotherapist and reinforced by
the
nursing team. The provision of such a service should be
within the
capabilities of general paediatricians and district
general hospitals.
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INTRODUCTION
ILLUSTRATIVE HISTORIES
