Skip to main content

Advertisement

SpringerLink
Log in

Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment

  • Psychological and Behavioral Aspects of Headache and Pain (D Buse, Section Editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This paper examines the overlap of conversion disorder with chronic pain conditions, describes ways to assess for conversion disorder, and provides an overview of evidence-based treatments for conversion disorder and chronic pain, with a focus on conversion symptoms.

Recent Findings

Conversion disorder is a significant problem that warrants further study, given that there are not many well-established guidelines. Accurate and timely assessment should help move treatment in a more fruitful direction and avoid unnecessary medical interventions. Advances in neuroimaging may also help further our understanding of conversion disorder. Creating a supportive environment and a collaborative treatment relationship and improving understanding of conversion symptoms appear to help individuals diagnosed with conversion disorder engage in appropriate treatments. Novel uses of earlier treatments, such as hypnosis and psychodynamic approaches, could potentially be beneficial and require a more vigorous and systematic study.

Summary

There are treatments that produce significant improvements in functioning and reduction of physical symptoms from conversion disorder even for very severe cases. Hypnotherapy, cognitive behavioral therapy, and inpatient multidisciplinary treatment with intensive physiotherapy for severe cases have the most evidence to support reduction of symptoms. Components of treatment for conversion disorder overlap with treatments for chronic pain and can be used together to produce therapeutic effects for both conditions. Treatment needs to be tailored for each individual’s specific symptoms.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth ed. Arlington: American Psychiatric Association; 2013.

    Book  Google Scholar 

  2. National Organization for Rare Disorders. Conversion disorder [Internet]. Rare disease information; 2016 [updated: 2003] Available from: https://rarediseases.org/rare-diseases/conversion-disorder/

  3. Nowack WJ. Epilepsy: a costly misdiagnosis. Clin Electroencephalogr. 1997;28:225–8.

    Article  CAS  PubMed  Google Scholar 

  4. Stone J, Binzer M, Sharpe M. Illness beliefs and locus of control: a comparison of patients with pseudoseizures and epilepsy. J Psychosom Res. 2004;57:541–7.

    Article  PubMed  Google Scholar 

  5. Parisod E, Murray RF, Cousins MJ. Conversion disorder after implant of a spinal cord stimulator in a patient with a complex regional pain syndrome. Anasthesia & Analgesia. 2003;96:201–6.

    Google Scholar 

  6. Shiri S, Tsenter J, Livai I, Vatine J. Similarities between the psychological profiles of complex regional pain syndrome and conversion disorder patients. J Clin Psychol Med Settings. 2003;10(3):193–9.

    Article  Google Scholar 

  7. Gazzola DM, Carlson C, Rugino A, Hirsch S, Starner K, Devinsky O. Psychogenic nonepileptic seizures and chronic pain: a retrospective case-controlled study. Epilepsy Behav. 2012;25:662–5.

    Article  PubMed  Google Scholar 

  8. Kozlowska K, Nunn KP, Rose D, Morris A, Ouvrier RA, Varghese J. Conversion disorder in Australian pediatric practice. Journal of American Academy of Adolescent Psychiatry. 2007;46(1):68–75.

    Article  Google Scholar 

  9. Shepard MA, Silva A, Starling AJ, Hoerth MT, Locke DC, Ziemba K et al. Patients with psychogenic nonepileptic seizures report more severe migraine than patients with epilepsy. Seizure. 2016;3478–3482.

  10. Benbadis SR. A spell in the epilepsy clinic and a history of “chronic pain” or “fibromyalgia” independently predict a diagnosis of psychogenic seizures. Epilepsy Behav. 2005;6:264–5.

    Article  PubMed  Google Scholar 

  11. Dixit R, Popescu A, Bagic A, Ghearing G, Hendrickson R. Medical comorbidities in patients with nonepileptic spells (PNES) referred for video-EEG monitoring. Epilepsy Behav. 2013;28:137–40.

    Article  PubMed  Google Scholar 

  12. • Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. Brain. 2010;133:1537–51. As one of the few controlled studies of symptoms of conversion disorder, the study is able to provide clinicians and researchers with helpful information regarding associated features and information to consider regarding differential diagnosis.

    Article  PubMed  Google Scholar 

  13. Ettinger AB, Devinksy O, Weisbrot DM, Goyal A, Shashikumar S. Headaches and other pain symptoms among patients with psychogenic nonepileptic seizures. Seizure. 1999;8:424–6.

    Article  CAS  PubMed  Google Scholar 

  14. Zhang YC, Bromfield EB, Hurwitz S, Nelson A, Sylvia K, Dworetsky BA. Comparison of outcomes of video/EEG monitoring between patients with epileptic seizures and those with psychogenic nonepileptic seizures. Epilepsy Behav. 2009;15(3):303–7.

    Article  PubMed  Google Scholar 

  15. Elliott JO, Charyton C. Biopsychosocial predictors of psychogenic nonepileptic seizures. Epilepsy Res. 2014;108:1543–55.

    Article  PubMed  Google Scholar 

  16. Marquez AV, Farias ST, Apperson M, Koopmans S, Jorgensen J, Shatzel A, Alsaadi TM. Psychogenic nonepileptic seizures are associated with an increased risk of obesity. Epilepsy Behav. 2004;5:88–93.

    Article  PubMed  Google Scholar 

  17. Tojek TM, Lumley M, Barkley G, Mahr G, Thomas A. Stress and other psychosocial characteristics of patients with psychogenic nonepileptic seizures. Psychosomatics. 2000;41:221–6.

    Article  CAS  PubMed  Google Scholar 

  18. de Wat CJ, Mellers JD, Gardner WN, Toone BK. Pseudoseizures and asthma. J Neurol Neurosurg Psychiatry. 2003;74:639–41.

    Article  Google Scholar 

  19. Stone J. Functional neurological symptoms. J R Coll Physicians Edinb. 2011;41(1):38–41.

    Article  CAS  PubMed  Google Scholar 

  20. • Stone J, Carson A. Functional neurological symptoms: assessment and management. Neurol Clin. 2011;29(1):1–18. It is an excellent review article that provides a good overview of positive clinical neurological signs that suggest conversion disorder.

    Article  PubMed  Google Scholar 

  21. Tremolizzo L, Susani E, Riva MA, Cesana G, Ferrarese C, Appollonio I. Positive signs of functional weakness. J Neurol Sci. 2014;340(1–2):13–8.

    Article  PubMed  Google Scholar 

  22. Sonoo M. Abductor sign: a reliable new sign to detect unilateral non-organic paresis of the lower limb. J Neurol Neurosurg Psychiatry. 2004;75:121–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Stone J, Carson A. Functional neurologic disorders. Continuum (Minneap Minn). 2015;21:818–37.

    Google Scholar 

  24. Lombardi TL, Barton E, Wang J, Eliashiv DS, Chung JM, Muthukumaran A, et al. The elbow flex-ex: a new sign to detect unilateral upper extremity non-organic paresis. J Neurol Neurosurg Psychiatry. 2014;85:165–7.

    Article  PubMed  Google Scholar 

  25. •• Ejareh Dar M, Kanaan RAA. Uncovering the etiology of conversion disorder: insights from functional neuroimaging. Neuropsychiatr Dis Treat. 2016;12:143–53. It is a great review article highlighting all the major functional imaging studies of conversion disorder and the corresponding anatomic areas involved in conversion disorder.

    PubMed  PubMed Central  Google Scholar 

  26. Aybek S, Vuilleumier P. Imaging studies of functional neurological disorders. Handb Clin Neurol. 2017;139:73–84.

    Article  Google Scholar 

  27. Voon V, Brezing C, Gallea C, Hallett M. Aberrant supplementary motor complex and limbic activity during motor preparation in motor conversion disorder. Mov Disord. 2011;26(13):2396–403.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Voon V, Gallea C, Hattori N, Bruno M, Ekanayake V, Hallett M. The involuntary nature of conversion disorder. Neurology. 2010;74(3):223–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Voon V, Brezing C, Gallea C, et al. Emotional stimuli and motor conversion disorder. Brain. 2010;133:1526–36.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Yaźići KM, Kostakoglu L. Cerebral blood flow changes in patients with conversion disorder. Psychiatry Res. 1998;83(3):163–8.

    Article  PubMed  Google Scholar 

  31. Aybek S, Nicholson TR, Zelaya F, et al. Neural correlates of recall of life events in conversion disorder. JAMA psychiatry. 2014;71(1):52–60.

    Article  PubMed  Google Scholar 

  32. Aybek S, Nicholson TR, O’Daly O, Zelaya F, Kanaan RA, David AS. Emotion-motion interactions in conversion disorder: an FMRI study. PLoS One. 2015;10(4):e0123273.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Graham JR. MMPI-2: assessing personality and psychopathology. New York: Oxford University Press; 2006.

    Google Scholar 

  34. Spitzer RL, Williams JBW, Kroenke K, Linzer M, deGruy IIIFV, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272:1749–56.

    Article  CAS  PubMed  Google Scholar 

  35. Spitzer RL, Kroenke K, Williams JBW. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA. 1999;282:1737–44.

    Article  CAS  PubMed  Google Scholar 

  36. Spitzer RL, Williams JBW, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric–gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics–Gynecology Study. Am J Obstet Gynecol. 2000;183:759–69.

    Article  CAS  PubMed  Google Scholar 

  37. Korber S, Frieser D, Steinbrecher N, Hiller W. Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting. J Psychosom Res. 2011;71:142–7.

    Article  PubMed  Google Scholar 

  38. Moene FC, Spinhoven P, Hoogduin KAL, vanDyck R. A randomized controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for inpatients with conversion disorder of the motor type. Psychother Psychosom. 2002;71:66–76.

    Article  PubMed  Google Scholar 

  39. LaFrance WC, Miller IW, Ryan CE, Blum AS, Solomon DA, Kelley JE, et al. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2009;14:591–6.

    Article  PubMed  Google Scholar 

  40. Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology. 2010;74:1986–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Kuyk J, Siffels MC, Badkvis P, Swinels WAM. Psychological treatment of patients with psychogenic nonepileptic seizures: an outcome study. Seizure. 2008;17:595–603.

    Article  PubMed  Google Scholar 

  42. •• McCormack R, Moriarty J, Mellers JD, Shotbolt P, Pastena R, Landes N, Goldstein L, Fleminger S, David AS. Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study. J Neurol Neurosurg Psychiatry. 2014;85:893–8. This is one of the few contemporary studies demonstrating the effectiveness of a comprehensive multimodal program for the treatment of severe conversion disorder. This approach bears a similarity to multidisciplinary and interdisciplinary treatment of chronic pain.

    Article  Google Scholar 

  43. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69(2):153–66.

    Article  PubMed  Google Scholar 

  44. Ataoglu A, Ozcetin A, Icmeli C, Ozbulut O. Paradoxical therapy in conversion reaction. J Korean Med Sci. 2003;18:581–4.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Pollak TA, Nicholson TR, Edwards MJ, David AS. A systematic review of transcranial magnetic stimulation in thte treatment of functional (conversion) neurological symptoms. J Neurol Neurosurg Psychiatry. 2014;85:191–7.

    Article  PubMed  Google Scholar 

  46. Goldstein LH, Deale AC, Mitchell O’Malley S, Toone BK, Mellers JDC. An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: a pilot study. Cog Behav Neurol. 2004;17(1):41–9.

    Article  Google Scholar 

  47. Lang EV. Patient sedation without medication: rapid rapport and quick hypnotic techniques a resource guide for doctors, nurses, and technologists. 1st ed. Seattle: Create Space Independent Publishing Platform; 2009.

    Google Scholar 

  48. Patterson DR. Clinical hypnosis for pain control. 1st ed. Washington D.C.: American Psychological Association; 2010.

    Book  Google Scholar 

  49. Lang EV, Berbaum KS, Faintuch S, Hatsiopoulou O, Halsey N, Li X, et al. Adjunctive self-hypnotic relaxation for outpatient medical procedures: a prospective randomized trial with women undergoing large core breast biopsy. Pain. 2006;126:155–64.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull. 2003;129(4):495–521.

    Article  PubMed  Google Scholar 

  51. Moene FC, Spinhoven P, Hoogduin KAL, van Dyck R. A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type. Int J Clin Exp Hypn. 2003;51(1):29–50.

    Article  PubMed  Google Scholar 

  52. Stone J, Edwards M. Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs. Neurology. 2012;79:282–4.

    Article  PubMed  Google Scholar 

  53. Barry JJ, Witenberg D, Bullock KD, Michaels JB, Classen CC, Risher RS. Group therapy for patients with psychogenic nonepileptic siezures: a pilot study. Epilepsy ad Behavior. 2008;13:624–9.

    Article  CAS  Google Scholar 

  54. Harden RN, Oaklander AL, Burton AW, Perez RSGM, Richardson K, Swan M, Barthel J, Costa B, Graciosa JR, Bruehl S. Complex regional pain syndrome: practical diagnostic and treatment guidelines, 4th edition. Pain Med. 2013;14(2):180–229.

    Article  PubMed  Google Scholar 

  55. Allen LA, Woolfolk RL, Escobar JI, Gara MA, Hamer RM. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial. Arch Intern Med. 2006;166:1512–8.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Dr. Christopher Robin Page for editing this paper and providing valuable feedback.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Chronic Pain Division Stony Brook Medicine, 3 Edmund Pellegrino Rd, Stony Brook, NY, 11794, USA

    Patricia Tsui

  2. Department of Psychiatry, Stony Brook University, 101 Nicolls Rd, Stony Brook, NY, 11794, USA

    Andrew Deptula

  3. Department of Neurology, Health Sciences Center T-12, 020, Stony Brook Medical Center, Stony Brook, NY, 11794, USA

    Derek Y. Yuan

Authors
  1. Patricia Tsui
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andrew Deptula
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Derek Y. Yuan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Patricia Tsui.

Ethics declarations

Conflict of Interest

Patricia Tsui, Andrew Deptula, and Derek Y. Yuan declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Psychological and Behavioral Aspects of Headache and Pain

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tsui, P., Deptula, A. & Yuan, D.Y. Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment. Curr Pain Headache Rep 21, 29 (2017). https://doi.org/10.1007/s11916-017-0627-7

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-017-0627-7

Keywords

Search

Navigation