INTRODUCTION — Conversion disorder (functional neurological symptom disorder) is characterized by neurologic symptoms (eg, weakness, abnormal movements, or nonepileptic seizures) that are inconsistent with a neurologic disease, but cause distress and/or impairment [1]. The disorder is common in clinical settings and often has a poor prognosis [2-5].
This topic reviews treatment of conversion disorder. The terminology, diagnosis, epidemiology, prognosis, clinical features, and assessment are discussed separately, as are specific subtypes of conversion disorder (psychogenic nonepileptic seizures and functional movement disorders):
●(See "Conversion disorder in adults: Terminology, diagnosis, and differential diagnosis".)
●(See "Conversion disorder in adults: Epidemiology, pathogenesis, and prognosis".)
●(See "Conversion disorder in adults: Clinical features, assessment, and comorbidity".)
●(See "Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis".)
●(See "Functional movement disorders".)
GENERAL PRINCIPLES — First line treatment for patients with conversion disorder (functional neurological symptom disorder) is education about the illness [6]. For conversion disorder that does not respond to education alone, second line treatment for patients with motor symptoms consists of physical therapy, either alone or with cognitive-behavioral therapy; for patients with symptoms other than functional motor symptoms, we suggest cognitive-behavioral therapy as second line therapy. No head-to-head trials have compared first and second line treatments.
For patients with conversion disorder who are treated by neurologists or primary care clinicians but do not respond to education, referral to a psychiatrist can be helpful [7]. A consultation liaison psychiatrist or neuropsychiatrist is often best equipped to assess the patient. Patients may be more inclined to accept referrals if they are told that the psychiatrist has experience in treating conversion symptoms and that the referral does not mean that the patient is “crazy.” Additional information about psychiatric referrals is discussed separately. (See "Somatic symptom disorder: Treatment", section on 'Choosing treatment'.)
In addition, multidisciplinary treatment can be helpful. A randomized trial compared multidisciplinary care with usual care in patients with conversion disorder (n = 23); multidisciplinary care consisted of four to six sessions of psychotherapy administered by a psychiatrist and neurologist over two months [8]. The group that received multidisciplinary care showed greater improvement of physical and psychological symptoms, and spent fewer days in the hospital during the one-year follow-up.
Comorbid anxiety or depressive disorders should be treated concurrently with conversion symptoms [9]. Treatment of these comorbid disorders is discussed separately. (See "Unipolar major depression in adults: Choosing initial treatment" and "Generalized anxiety disorder in adults: Management".)
FIRST LINE TREATMENT — First line treatment for conversion disorder (functional neurological symptom disorder) is education about the diagnosis, based upon observational studies [10-12]. As an example, a prospective study of 54 patients with psychogenic nonepileptic seizures found that after the diagnosis was explained, recovery occurred immediately in 44 percent [13]. However, some patients subsequently suffered a recurrence.
A credible explanation of the diagnosis that creates a therapeutic alliance with the patient is an essential platform for any further treatment that is required [14]. Patients who do not believe the diagnosis are unlikely to cooperate with additional treatment; rather, they may continue the search for a more convincing disease explanation from another doctor. Treatment failures can often be attributed to insufficient attention to education.
Therapeutic engagement of patients with conversion disorder often requires repeated explanations of the rationale for the diagnosis. Thus, clinicians who administer treatment should understand how the diagnosis was made on the basis of the physical characteristics of the symptoms. If multiple clinicians (eg, primary care physician, neurologist, psychiatrist, and physical therapist) are treating the patient, the explanation of the diagnosis must be consistent [15]. With successful engagement, patients become more willing to take some responsibility with the aid of clinicians for getting better, which can reduce feelings of powerlessness, frustration, and mistrust for both patients and clinicians.
Presenting the diagnosis — There is a consensus that treatment of conversion disorder begins with education about the syndrome [9-12]. For a minority of patients, an explanation of the diagnosis along with encouragement may be all that is necessary for recovery.
In discussing the diagnosis of conversion disorder, we generally [7,9,12,14-16]:
●Ask patients what they think is wrong and whether the problem is caused by damage to their body.
●State that the symptoms are taken seriously and are real rather than feigned.
●Provide a diagnosis rather than simply telling patients that “there is no disease.” There are several diagnostic terms; the choice depends upon how the clinician conceptualizes the disorder:
•Functional neurological symptom disorder
•Conversion disorder
•Dissociative disorder
•Somatization
•Psychogenic
The issue of whether the patient’s problem is viewed as purely a mental health issue (conversion or psychogenic) or as a disorder at the interface of neurology and psychiatry is important for clinicians to decide for themselves. However, it is best to avoid a struggle with patients over which term is used. How the term is used is probably more important than the specific choice. Additional information about the terminology for conversion disorder is described separately. (See "Conversion disorder in adults: Terminology, diagnosis, and differential diagnosis", section on 'Terminology'.)
●Discuss how the diagnosis was made, including the clinical features and physical signs that are inconsistent with neurologic disease. As an example, patients with a positive Hoover’s sign can be told that the examination confirms that when they try to move the affected limb, the brain does not transmit messages correctly to the leg, but the movement seen in the affected limb when they move their unaffected leg shows that the problem is due to abnormal nervous system functioning rather than damage of neurologic pathways [14]. Hoover’s sign is discussed separately. (See "Conversion disorder in adults: Clinical features, assessment, and comorbidity", section on 'Examination'.)
●Emphasize the mechanism underlying the symptoms rather than the cause. As an example, patients can be told that the problem is result of abnormal functioning of the nervous system, rather than structural damage. Alternatively, symptoms can be described as a “software” problem rather than a “hardware” problem.
For patients with conversion symptoms who want to know the cause, we generally acknowledge that although it is possible to speculate, the causes are complex and often uncertain. However, we emphasize that despite this uncertainty we can nevertheless diagnose and treat the problem [7]. In addition, we state that the etiology is unknown for many other illnesses, such as primary epilepsy and migraine.
●Where relevant, explain that the patient does not have a neurologic disease such as multiple sclerosis, epilepsy, or stroke. However, note that the diagnosis of conversion disorder can still be made in the presence of neurologic disease as long as the conversion symptoms are not adequately explained by that disease.
●Emphasize that the symptoms are potentially reversible (unlike many neurologic diseases). Patients can be told that although their bodies are not functioning properly, improvement is possible because there is no structural damage.
●Acknowledge concerns about a psychiatric label if used, and difficulties in understanding the diagnosis.
●Discuss that it is important to identify and treat comorbid depression and anxiety because they can worsen conversion symptoms.
●Explain that understanding and accepting the diagnosis often leads to improvement because it allows proper engagement with rehabilitation rather than being stuck wondering or worrying about what is wrong.
●Attempt to enlist family members in helping patients understand the diagnosis.
●Tell patients that although they did not bring about the symptoms, they need to actively participate in their rehabilitation (eg, working on graded exercise or distraction techniques) in order to improve.
●Acknowledge any prior treatment that was unsatisfactory.
●Arrange a follow-up consultation with the clinician responsible for making the diagnosis to:
•Assess the extent to which the patient understands and believes the diagnosis
•Provide further explanation
•Answer additional questions from the patient and family
Information for patients — As part of education about conversion disorder, we typically provide written information that patients can review at home and share with family and friends [9]. General information about conversion disorder that can be downloaded and printed is available at the website www.neurosymptoms.org; information specific to psychogenic nonepileptic seizures is available at www.nonepilepticattacks.info. In addition, for those patients who are treated by primary care clinicians and have consulted a psychiatrist or neurologist, a copy of the letter from the consultant to the primary care clinician can be given to patients.
Further information about conversion disorder is provided in a book that is intended for patients and family members: Overcoming Unexplained Neurological Symptoms: A Five Areas Approach, written by Professor Christopher Williams, Catriona Kent, Dr. Sharon Smith, Dr. Alan Carson, Professor Michael Sharpe, and Dr. Jonathan Cavanagh (ISBN 9781444138344, published by Hodder Arnold, 2011). One of the book’s authors is also an author of this topic.
SECOND LINE TREATMENT — Conversion disorder (functional neurological symptom disorder) usually does not respond to education alone. In these cases, it’s important to establish whether the patient needs more time to understand the diagnosis or does not agree with the diagnosis, even if it has been presented carefully. Patients who cannot accept the diagnosis are unlikely to benefit from other treatments. First line treatment should be revisited or the clinician should explicitly discuss the problem of trying to embark on further treatment if the patient thinks the diagnosis is wrong.
For conversion disorder with functional motor symptoms, we suggest physical therapy as second line therapy [12,17-20]. However, psychological therapy, especially cognitive-behavioral therapy (CBT), is often used as well, either concurrently or sequentially (afterwards). Patients may decline psychotherapy because they refuse to accept that “talking” treatments can be beneficial for physical symptoms. This concern can often be addressed by delivering psychotherapy as part of medical care.
For conversion disorder with symptoms other than functional motor symptoms that do respond to education, we suggest cognitive-behavioral therapy as second line therapy. However, psychotherapy is not effective in all cases.
Physical therapy — For patients with conversion motor symptoms, we typically offer physical therapy in addition to CBT, or physical therapy alone if CBT is declined, not indicated, or not available. Physical therapy is essential for patients who acquire a physical disability (eg, contractures) [20]. Detailed recommendations for treating functional motor disorders with physical therapy are available [20]. Treatment is based upon a biopsychosocial etiological model and is directed at changing illness beliefs, decreasing abnormal self-directed attention, and reducing abnormal movements through:
●Education (see 'First line treatment' above)
●Eliciting normal movements
●Movement retraining by diverting attention
The essential element of physical therapy for motor conversion symptoms is to encourage normal movement and to teach patients to suppress abnormal movements or deficits as much as possible [17,20-22]. Attention to the affected limb tends to worsen function, whereas exercises involving distraction or superimposition of movement may help. As an example, a patient with unilateral functional tremor may benefit from superimposing a “sweeping” movement like an orchestral conductor and then being trained to gradually diminish the amplitude and frequency of the tremor. Physical therapy may incorporate findings from bedside tests like Hoover's sign to begin to generate more "automatic" normal movement. However, it is generally more beneficial to address activities such as transfers and walking than impairments such as weakness [23]. For patients who have fallen, therapy emphasizes increasing confidence in standing and walking, and when possible, reducing reliance on walking aids. In addition, graded exercise consistent with the same principles that are used for chronic fatigue syndrome (also known as myalgic encephalomyelitis/chronic fatigue syndrome), may be helpful [24].
Several studies support the use of physical therapy for conversion symptoms [17,19,21,25,26]:
●A randomized trial compared three weeks of inpatient physical therapy (including education) with a waiting list control condition in hospitalized patients with psychogenic gait disorder (n = 60) [18]. Ambulation and functional independence improved significantly more with physical therapy, the clinical effect was large, and the benefits were maintained at the one-year follow-up.
●A second randomized trial compared a five-day, intensive outpatient specialized physical therapy program with standard neurological physical therapy in patients with functional motor disorders (n = 60) [27]. The control group received an average of five sessions. At six-month follow-up, improvement occurred in four times as many patients in the intervention group than the controls (72 versus 18 percent).
Cognitive-behavioral therapy — The type of CBT used for conversion disorder combines cognitive therapy and behavioral therapy and thus resembles other forms of CBT that are used to treat anxiety disorders, unipolar depressive disorders, bipolar disorders, and chronic fatigue syndrome. Cognitive therapy attempts to modify dysfunctional thoughts and illness beliefs about conversion symptoms; one technique is cognitive restructuring, which involves reframing distorted thoughts by empirically testing them and considering more benign explanations. Behavioral therapy aims to change problematic behavioral responses to symptoms, dysfunctional thoughts, and environmental stimuli; specific behavioral techniques include desensitization (administering progressively greater exposure to feared and avoided situations and symptoms), problem solving (identifying the problem, generating multiple solutions, considering the consequences of each solution, choosing one solution, and acting upon it), progressive muscle relaxation, abdominal breathing exercises, and physical exercise. CBT principles and techniques are typically taught to patients by therapists, according to a manual.
Psychotherapy for conversion disorder requires an initial assessment of the predisposing, precipitating, and perpetuating factors to generate a case formulation (table 1) [15]. A practical guide for administering CBT is shown in the table (table 2).
Examining the association between current conversion symptoms and prior life events may be helpful. However, this is often difficult to achieve and may be appropriate only later in treatment, if at all [7]. It is not always necessary or desirable to provide a complete psychological explanation of conversion symptoms to improve them. If treatment eventually uncovers psychological problems or life events that predated the conversion symptoms, we generally avoid reattributing the conversion symptoms to the stressors; rather, we emphasize that psychological issues may worsen conversion symptoms. Patients may also disengage from psychotherapy because therapists are overzealous in attributing current symptoms to past traumas. This can harm patients at a point when they need help understanding their symptoms.
Evidence supporting CBT for conversion disorder includes randomized trials:
●A trial compared CBT plus usual care with usual care alone in 125 patients with functional neurologic symptoms [28]. CBT was administered in a clinician-guided format in which patients received a workbook and up to four sessions (each lasting 30 minutes) with a clinician who provided guidance. The book explained that functional symptoms were the result of changes in nervous system functioning due in part to psychological and behavioral factors, gave examples of common functional symptoms and their associated anatomy and physiology, discussed how functional symptoms are diagnosed, and suggested self-help techniques to reduce dysfunctional thoughts and improve coping with symptoms. At six months, the presenting symptoms improved in more patients who received CBT plus usual care than usual care alone (47 versus 30 percent). In addition, adjunctive CBT led to better physical functioning and less anxiety.
●Other trials in patients with psychogenic nonepileptic seizures indicate that CBT is superior to standard care. (See "Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis".)
●Systematic reviews of trials indicate that CBT is often moderately efficacious for somatic symptom and related disorders in general. (See "Somatic symptom disorder: Treatment", section on 'Psychiatric treatment'.)
THIRD LINE TREATMENT — Conversion disorder (functional neurological symptom disorder) often does not respond to first or second line treatments; for these refractory patients, we suggest one of the following:
●Pharmacotherapy
●Hypnosis
●Brief psychodynamic psychotherapy
●Multidisciplinary inpatient treatment
●Family therapy
●Group therapy
The order of preference depends upon the nature of the patient’s conversion disorder symptoms (including type, severity, and chronicity), whether comorbidity is present, and the availability of therapies. These aspects are discussed in the subsections below.
In addition, the choice of treatment depends upon the ability of the patient to engage with particular treatments. It is often counterproductive to force a treatment upon patients who are skeptical of it.
Pharmacotherapy — Patients with conversion disorder may possibly benefit from medications [29,30]. Pharmacotherapy (eg, antidepressant) is more widely available and easier to administer than hypnosis, psychodynamic psychotherapy, and inpatient treatment.
The most commonly used drugs for conversion disorder are antidepressants [31]. Comorbid anxiety or depressive disorders are often an indication to use antidepressants, such as selective serotonin reuptake inhibitors. The presence of pain, especially in the context of anxiety or depression, is also an indication for antidepressants, and it may be possible to use one medication to manage pain, anxiety/depression, and conversion disorder.
Indirect evidence supporting the use of antidepressants for conversion disorder includes systematic reviews that suggest antidepressants can be useful for somatoform disorders in general. (See "Somatic symptom disorder: Treatment", section on 'Antidepressants'.)
Additional information about the efficacy of antidepressants for conversion disorder is discussed separately in the context of psychogenic nonepileptic seizures. (See "Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis".)
Choosing pharmacotherapy for anxiety disorders, depressive disorders, and chronic pain is discussed elsewhere. (See "Unipolar major depression in adults: Choosing initial treatment" and "Approach to the management of chronic non-cancer pain in adults" and "Generalized anxiety disorder in adults: Management".)
Hypnosis — Hypnosis may be useful for patients with conversion disorder that includes symptoms of sensory loss or speech disturbance [12]; it is difficult to demonstrate transient reversibility of these symptoms using other treatment modalities. In addition, hypnosis lends itself to introducing relaxation techniques for patients who do not want psychotherapy. Hypnosis is a form of suggestion and is generally not offered to patients who are skeptical of or disapprove the intervention.
During hypnosis, concentration and physical relaxation are induced by asking the patient to focus upon an external object. In this relaxed, trance-like state, patients are thought to be more susceptible to suggestions aimed at alleviating symptoms or expressing emotions [32,33]. Hypnosis can be used to demonstrate the diagnosis of conversion disorder to patients if the symptoms disappear under hypnosis. Some patients can be trained to use self-hypnotic techniques to change their bodily sensations and functions.
Evidence supporting the use of hypnosis for conversion disorder includes two randomized trials:
●A three-month trial compared hypnosis (at least 10 weekly sessions, as well as daily self-hypnosis homework) with a waiting list control group in 44 outpatients with conversion symptoms and found that improvement was greater in patients who received hypnosis [34]. Follow-up assessments of the active treatment group six months post-treatment suggested that treatment gains were sustained.
●A two-month trial compared adjunctive hypnosis (eight weekly sessions, as well as daily self-hypnosis) with adjunctive psychotherapy that focused upon stressors (eight weekly sessions, as well as daily writing about stressors) in 45 hospitalized patients with conversion symptoms who all received multidisciplinary treatment [35]. Improvement was comparable for both groups.
Psychodynamic psychotherapy — Brief, individual, psychodynamic psychotherapy has been adapted for conversion symptoms and is often preferred for patients who have interpersonal difficulties or a history of traumatic events. The treatment is more suitable for patients who are psychologically minded and can understand complex ideas.
Psychodynamic psychotherapy is based upon the assumption that conversion disorder is caused or exacerbated by a pattern of dysfunctional interpersonal relationships that typically originates earlier in life [36]. In administering therapy, clinicians make tentative suggestions about the link between symptoms and relationships, offer support, avoid confrontation, and encourage patients to change their problematic interpersonal behavior and to express emotions more effectively (particularly with regard to unresolved past issues such as abuse, neglect, or losses). The goal is to develop insight and reduce the use of conversion symptoms as a defense against anxiety and conflict. Additional information about psychodynamic psychotherapy is discussed separately in the context of unipolar major depression. (See "Unipolar depression in adults: Psychodynamic psychotherapy".)
Evidence supporting psychodynamic psychotherapy for conversion disorder includes prospective observational studies:
●A study in 63 patients found that therapy (median of six sessions, each lasting 50 minutes) was associated with improved psychosocial functioning, less overall psychopathology, and a reduced number of physical symptoms [36].
●A study in 47 patients with psychogenic nonepileptic seizures found that response (50 percent or greater reduction in the number of nonepileptic seizures) occurred in 66 percent of patients [37].
In addition, systematic reviews of randomized trials indicate that for somatic symptom and related disorders in general, psychodynamic psychotherapy may be beneficial [38,39].
However, a small randomized trial compared short-term psychodynamic psychotherapy with neurologic observation in 15 patients with functional movement disorder; the study was characterized by high dropout rates and found no advantage for active treatment [40].
Family therapy — Patients with conversion disorder may possibly benefit from an assessment of family functioning in domains such as communication, problem solving, and roles. Identified problems (eg, expression of suppressed affect) that perpetuate symptoms can then be addressed in short-term, structured, family therapy. A review of observational studies found that family therapy may perhaps improve symptoms [9]. Assessment of family functioning and administration of family therapy are discussed separately in the context of unipolar major depression. (See "Unipolar depression in adults: Family and couples therapy".)
Group therapy — Group therapy can reinforce education about conversion disorder and allows patients to learn from each other [9]. However, mixed results have been found in observational studies of patients with psychogenic nonepileptic seizures. (See "Psychogenic nonepileptic seizures: Etiology, clinical features, and diagnosis".)
Inpatient treatment — Multidisciplinary inpatient treatment with both physical and psychological rehabilitation is indicated for patients with more severe and chronic physical disabilities (eg, using a wheel chair or heavily dependent upon walking aids) [12]. The presence of comorbid psychopathology in conjunction with the physical disabilities further suggests that patients may need inpatient treatment.
Observational studies suggest that treating patients with severe conversion disorder on specialist inpatient units may be beneficial [41,42]. As an example, a prospective observational study assessed patients (n = 66) who were hospitalized on a specialist unit for severe conversion disorder (mixed subtype) and received a four-week multidisciplinary program that included physical therapy, occupational therapy, cognitive-behavioral therapy, neuropsychiatry assessment, and neurology input as required. Improvement of psychiatric symptoms, behavior, and functioning at discharge was significant and clinically large, according to clinician ratings [43]. In addition, general health was rated as “better” or “much better” by 66 percent of patients, both at discharge and the one-year follow-up assessment.
OTHER INTERVENTIONS — For patients with conversion disorder (functional neurological symptom disorder) who do not respond to consecutive trials of first, second, and third line treatments, repetitive transcranial magnetic stimulation (TMS) or sedation may perhaps help, as may biofeedback for functional tremor.
Repetitive transcranial magnetic stimulation (TMS) — TMS may perhaps have limited benefits for conversion disorder:
●A trial enrolled patients with functional movement disorders (n = 33) and randomly assigned them to one of two groups; group 1 received low frequency TMS on day 1 and low frequency spinal root magnetic stimulation on day 2, and group 2 had the same treatments in reverse order [44]. TMS was administered over the cortex contralateral to the symptoms and spinal root magnetic stimulation over the roots homolateral to the symptoms. Improvement (reduction of baseline symptoms ≥50 percent) occurred in 66 percent of the patients; however, the benefit of TMS and spinal root magnetic stimulation was comparable, suggesting that improvement was related to nonspecific therapeutic effects rather than specific neuromodulation.
●Another study randomized subjects with functional upper limb weakness to immediate (n = 7) or delayed (n = 3) TMS, and failed to show any sustained improvement in any patient, possibly because the patients that had already failed first and second line therapies (as listed above) [45].
●A third study assigned patients with functional limb weakness (n = 11) to TMS or placebo, and then crossed them over to the other condition at least two months later; no symptomatic advantage for TMS was observed [46].
Sedation — Sedation may transiently improve conversion symptoms. Based upon clinical experience, a positive therapeutic relationship should be established prior to using sedation.
A retrospective study examined 11 patients with functional motor symptoms who received therapeutic sedation with propofol and were followed for a median of 30 months; substantial improvement or recovery occurred in 5 (45 percent) [47]. In addition, a case report described using sedation to help persuade a patient that the symptoms were reversible, and to provide an experience of moving a limb that was functionally paralyzed [48].
Abreaction — Abreaction (narcotherapy) is a rarely used technique that takes sedation one step further and involves interviewing patients who are lightly sedated (relaxed but not drowsy) with a drug administered intravenously [32,49]. During the procedure, patients may become more receptive to explanations about the nature of their disorder, which may lead to improvement. Based upon clinical experience, a positive therapeutic relationship should be established prior to using abreaction. A pooled analysis of 55 observational studies (19 of the studies predate 1950) in 116 patients with conversion disorder found that recovery occurred in 79 percent [50].
Biofeedback — Biofeedback may help functional tremor. In a prospective observational study (n = 10), patients “retrained” their tremor frequency over a period of two to six hours, using equipment that measured joint angles and provided tactile cueing and real time visual feedback on a computer screen [51]. Follow-up three to six months later found that three patients remained tremor free and that improvement persisted in two other patients.
Techniques to avoid — We avoid treatment techniques in which patients are subjected to reverse psychology (also called paradoxical intention; eg, “You are not allowed to get up from that wheelchair” [52]), are told that they have a spinal cord concussion [22], or are told that full recovery constitutes proof of a physical etiology and failure to recover constitutes conclusive evidence of a psychiatric etiology [53]. Although some clinicians report that these techniques can be effective, we think that comparable or better results are possible without deceiving patients and risking the loss of trust that can arise from these questionable approaches. In addition, surgery for conversion disorder (eg, deep brain stimulation for movement disorder) should be avoided [20].
PERSISTENTLY ILL PATIENTS — Patients with conversion disorder (functional neurological symptom disorder) often do not improve with consecutive trials of first, second, and third line treatments as well as other interventions. It is not realistic to expect that patients will necessarily improve because they do not have recognizable disease pathology. Persistently ill patients should generally be treated by primary care clinicians with a conservative approach that avoids excessive investigations and treatments, and includes regular visits to monitor for general medical and psychiatric illnesses. Management of patients with chronic somatic symptoms by primary care clinicians is discussed separately. (See "Somatic symptom disorder: Treatment", section on 'Treatment-refractory patients'.)
Conversion disorder may not respond to treatment for several reasons, including [7,54]:
●Symptom severity and chronicity – Symptoms may be so severe or chronic that they are not amenable to treatment.
●Diagnostic doubt – Some patients simply don’t accept the diagnosis and continue to seek additional opinions, investigations, and medical or surgical solutions to their symptoms.
●Poor motivation to improve – Patients have often resigned themselves to living with their symptoms.
●Disability payments comparable to money earned at an unpleasant job.
●Litigation in pursuit of disability payments.
●Symptoms that engage others to provide social support.
●Inexperienced clinicians – Patients are easily alienated by clinicians who may inadvertently worsen the situation. A common mistake is to attribute conversion symptoms to psychological issues that are either not present or not related to the symptoms. Another common error is to point out the connection between symptoms and psychological issues before patients are ready to consider such explanations.
●Misdiagnosing conversion disorder in patients with:
•Factitious disorder (willfully feigning symptoms to obtain medical care) (see "Factitious disorder imposed on self (Munchausen syndrome)")
•Malingering (faking symptoms to obtain obvious benefits such as money)
•Recognizable disease with a known pathologic basis
The differential diagnosis and prognosis of conversion disorder are discussed separately. (See "Conversion disorder in adults: Terminology, diagnosis, and differential diagnosis", section on 'Differential diagnosis' and "Conversion disorder in adults: Epidemiology, pathogenesis, and prognosis", section on 'Prognosis'.)
SUMMARY AND RECOMMENDATIONS
●For patients with conversion disorder (functional neurological symptom disorder), we suggest education about the diagnosis as first line treatment rather than other therapies (Grade 2C). (See 'First line treatment' above.)
Education about conversion disorder includes eliciting how patients conceptualize their symptoms, stating that the symptoms are real and taken seriously, giving a diagnostic label, discussing how the diagnosis was made, emphasizing that the symptoms are potentially reversible, reassuring patients that understanding the diagnosis can lead to improvement, explaining that the patient does not have a neurologic disease, enlisting family members to help patients understand the diagnosis, describing self-help techniques that can foster improvement, acknowledging prior treatment that was unsatisfactory, and providing at least one follow-up visit. (See 'Presenting the diagnosis' above.)
●Written information describing the diagnosis and management of conversion disorder is often helpful. (See 'Information for patients' above.)
●Conversion disorder (functional neurological symptom disorder) often does not respond to education. In these cases, it’s important to establish whether the patient needs more time to understand the diagnosis or does not agree with the diagnosis. Patients who cannot accept the diagnosis are unlikely to benefit from other treatments. First line treatment should be revisited or the clinician should explicitly discuss the problem of trying to embark on further treatment if the patient thinks the diagnosis is wrong. (See 'Second line treatment' above.)
●For patients with conversion disorder who understand and accept the diagnosis of conversion disorder, but do not respond to first line treatment (education), we suggest physical therapy for motor symptoms as second line treatment (Grade 2C) and cognitive-behavioral therapy (table 2) for other symptoms (Grade 2B). (See 'Second line treatment' above.)
●Refractory patients with conversion disorder who do not respond to first or second line treatment may benefit from third line treatments, including pharmacotherapy, hypnosis, brief psychodynamic psychotherapy, family therapy, group therapy, or multidisciplinary inpatient treatment. Other treatments that may be used adjunctively, and which probably work primarily through nonspecific therapeutic mechanisms, include transcranial magnetic stimulation and sedation (with or without abreaction). (See 'Third line treatment' above and 'Other interventions' above.)
●Patients with conversion disorder who do not respond to first, second, and third line treatments, as well as other adjunctive interventions, should generally be treated with a conservative approach that avoids excessive investigations and treatments, and includes regular reviews to monitor for general medical and psychiatric illnesses. (See 'Persistently ill patients' above and "Somatic symptom disorder: Treatment", section on 'Treatment-refractory patients'.)
