Advances in Psychiatric Treatment (2006), vol.

12, 152–157

Conversion disorder: the modern hysteria

Colm Owens & Simon Dein

Abstract Conversion disorders tend to be poorly understood and diagnosis can be difficult. In this article, we
aim to clarify what conversion disorders are and how they can be distinguished from other psychiatric
disorders that involve physical symptoms. Prevalence, prognosis and relationship to organic disease are
controversial areas; we outline what is known about them and provide some historical context. Aetiological
theories and management strategies are discussed, the latter with the aid of case vignettes.

All doctors have encountered patients whose Table 1  Comparative categorisation of conversion
symptoms they cannot explain. These individuals disorder
frequently provoke despair and disillusionment. DSM–IV category ICD–10 approximation
Many doctors make a link between inexplicable
Conversion disorder F44.4 Dissociative motor
physical symptoms and assumed psychiatric ill­
disorders
ness. An array of adjectives in medicine apply
to symptoms without established organic basis F44.5 Dissociative convulsions
– ‘supratentorial’, ‘psychosomatic’, ‘functional’ – and F44.6 Dissociative anaes­thesia
these are sometimes used without reference to their and sensory loss
real meaning. In psychiatry, such symptoms fall
under the umbrella of the somatoform disorders,
which includes a broad range of diagnoses.
Conversion disorder is just one of these. Its meaning Organization, 1992) conversion disorder falls under
is not always well understood and it is often the category of dissociative (conversion) disorders
confused with somatisation disorder.† Our aim (F44.–), alongside dissociative amnesia and fugue
here is to clarify the notion of a conversion dis­order states (Table 1). In ICD–10, somatoform disorders
(and the differences between conversion and other fall into a different category entirely.
somatoform dis­orders) and to discuss prevalence, According to DSM–IV criteria (American Psy­chi­
aetiology, management and prognosis. atric Association, 1994: p. 457), conversion disorder
is characterised by:
one or more symptoms affecting voluntary
What is a conversion disorder •
motor or sensory function
and how is it classified? • resemblance to neurological or medical
disease
The diagnosis of conversion disorder has always • involvement of psychological factors
been controversial. In DSM–IV (American Psychia­tric • unintentional, unfeigned symptoms.
Associ­ation, 1994) it is categorised as a somatoform
disorder (445), along with somatisation disorder,
hypochondriasis, body dysmorphic disorder and Common symptomatology
pain disorder. Con­fusingly, in ICD–10 (World Health
Table 2 lists the symptoms most commonly found in
conversion disorder and Box 1 shows its differential
†
S omatisation disorders were discussed in the previous diagnosis. The patterns of defects do not usually
issue of APT: see Patel & Sumathipala (2006) Psychological conform to recognised anatomical pathways,
approaches to somatisation in developing countries. Advances and symptoms may fluctuate and intensify when
in Psychiatric Treatment, 12, 54–62. Ed.
patients are aware that staff are observing them.

Colm Owens is a specialist registrar in old age psychiatry at Chase Farm Hospital (Enfield, Middlesex EN2 8JL, UK. E-mail: colm.owens@
beh-mht.nhs.uk.). Simon Dein is a senior lecturer in medical anthropology at University College London and honorary consultant
neuropsychiatrist at Princess Alexandra Hospital, Harlow, Essex. Both authors have an interest in liaison psychiatry. Simon Dein has
extensive experience of treating patients with conversion disorders and also has an interest in hypnotherapy.

152
 Conversion disorder

Table 2  Common symptoms of conversion disorder

Box 2  Changing nomenclature
Sensory symptoms Motor symptoms
Diplopia Paralysis 1952 DSM–I Conversion reaction
Blindness Dysphasia 1968 DSM–II Hysterical neurosis
(conversion type)
Deafness Ataxia
1980 DSM–III Conversion disorder
Numbness Tremor
Aphonia 1992 ICD–10 Dissociative (conversion)
Seizures disorder
1994 DSM–IV Conversion disorder

Historical background
In the first edition of the DSM (now known as DSM–I) and ‘conversion’ disorders. Conversion disorder
(American Psychiatric Association, 1952), conversion was separated from dissociation disorder and
disorder appeared as ‘conversion reaction’ (Box 2). categorised as a somato­form disorder. Thus, since
In DSM–II (1968), it was grouped with dissociation 1980, the somatoform disorders and the dissociative
disorder under the new diagnostic category of disorders have been separate categories in the DSM.
‘hysterical neurosis’, a title echoing the early The characterisation of DSM somatoform disorders
concept of ‘hysteria’ resulting from uterine disorder is by disturbances in physical sensations, or inability
in women (see ‘Theories of conversion disorder’ to move the limbs or walk, whereas DSM dissociative
below). Subsequently, conversion disorder was disorders involve involuntary disturbance in the
conceptualised as a disorder of the brain associated sense of identity and memory.
with disordered emotions. The transition within the Somatoform and dissociative disorders are now
DSM to a system that classified psychiatric disorders also separated in the ICD classificatory system but,
by clinical phenomenology rather than aetiology as outlined above, conversion disorder falls  under
resulted in the elimination of ‘hysterical neurosis’ the category of dissociative disorders.
from DSM–III (Ameri­can Psychiatric Association, Conversion disorder is thought to occur primarily
1980) and its replacement by ‘dissociation’ disorders in societies with strict social systems that prevent
individuals from directly expressing feelings and
emotions towards others. Temporary somatic
dysfunction is one possible mode of communication,
Box 1  Differential diagnosis of conversion particularly for those who are oppressed or
disorder underprivileged. The ‘psychological mindedness’
and ease of emotional expression typical of modern
Organic medical/neurological illness developed societies have led to the increasing rarity
Somatisation  Multiple, recurrent and frequent­ of conversion disorders in developed countries
ly changing physical symptoms over a lengthy (Tseng, 2001).
period. Preoccupation with these symptoms,
leading to marked distress in the patient: ‘I’ve
got all these pains, why can’t they find out Prevalence
what’s wrong with me?’
Hypochondriasis  Preoccupation with having Although many in the medical profession have
one (or more) serious physical illness, despite formed the impression that the prevalence of
evidence to the contrary: ‘I know I’ve got conversion disorders in developed countries is in
cancer, they just haven’t done the right test decline, there is little recent information. Much
yet’. of the information we have about prevalence is
derived from earlier studies, which often suggest
Factitious disorder  Intentional feigning of that conversion symptoms are relatively common.
symp­toms with unclear motivation: the Farley et al’s (1968) findings in a study of 100
patient does not know why they are doing it. mothers of new born children suggested a lifetime
Also known as Munchhausen’s syndrome. prevalence of up to 33%. Engl (1983) estimated that
Malingering  Intentional feigning of symptoms 25% of patients admitted to general medical services
with clear motivation: the patient does know had had conversion symptoms at some time in
why they are doing it. their lives. Stephansson et al (1976) estimated the
annual incidence to be about 22 cases per 100 000.

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Owens & Dein

Other studies suggest that the symptoms are most Learning theory
common in young women (Lazare,1981), rare in
children under 8 years old (Perley & Juze, 1962) and In a model that emphasises the shaping of behaviour
more common in rural areas, among uneducated by the environment, conversion symptoms are seen
people and in the lower socio-economic classes as maladaptive operant behaviours that act on the
(Stephansson et al, 1976). The prevalence of these environment to produce reinforcing consequences
symptoms is generally felt to be higher among (secondary gains). Conversion disorder is then
patients from minority ethnic groups. However, sustained by the effects of these behaviours (McHugh
there is a lack of empirical data to support this & Slavney, 1998: pp. 223–237). The therapeutic
assertion. implications of this theory are that it is important
to alter the patient’s belief by means of counter­
suggestion and to take psychosocial measures to
Theories of conversion disorder reduce the external benefits associated with the sick
role. The aim of behavioural approaches is to ensure
Conversion has been attributed to many different that the patient gains more from relinquishing
mechanisms. One influential theory, dating back symptoms than from maintaining them.
to Ancient Greek physicians who thought the
symptoms specific to women, invoked as their cause
the wandering of the uterus (hustera), from which the The sociocultural hypothesis
word hysteria derives. The term conversion was first Sociocultural formulations of conversion disorder
used by Freud and Breuer to refer to the substitution observe that in some cultures the direct expression
of a somatic symptom for a repressed idea (Freud, of intense emotions is prohibited. As mentioned
1894). This behaviour exemplifies the psychological above, this may predispose people to exhibit
concept of ‘primary gain’, i.e. psychological anxiety conversion symptoms as a more acceptable form of
is converted into somatic symptomatology, which communication. Conversion disorder would thus
lessens the anxiety and gives rise la belle indifference, represent non-verbal communication of a forbidden
where a patient seems surprisingly unconcerned idea or feelings. Such prohibitions can be reinforced
about their physical symptoms. The ‘secondary gain’ by gender roles, religious beliefs and sociocultural
of such a reaction is the subsequent benefit that a influences (Schwartz et al, 2001). The expression of
patient may derive from being in the sick role. intense emotions in culturally defined rituals can be
As David & Halligan (2000) point out, the concept part of the healing process.
of conversion disorder has raised great controversy
between the proponents of psychological and physio­
logical models of mental states. Conversion disorder Neurophysiology: the inhibition
raises the intriguing philosophical problem of how
it is that psychological or mental states can effect
of willed movements
long-term motor, sensory and cognitive changes in There is evidence suggesting that conversion dis­
people claiming not to be consciously responsible order is associated with impairment of cortical
for them. Theories falls into three main groups: and subcortical functioning. Flor-Henri et al (1981)
psychoanalytic, learning theory and sociocultural demonstrated impairment of both the dominant and
formulations. non-dominant cerebral hemispheres in conversion
disorder, the impairment being greatest in the
Psychoanalytic theories former.
In an influential research project Vuilleumier et al
Psychoanalytic explanations of conversion disorder (2001) studied seven people with unilateral hysterical
emphasise unconscious drives, including sexuality, sensorimotor loss in one arm. Positron emission
aggression or dependency, and the internalised computed tomography during passive vibratory
prohibition against their expression (Hollander, stimulation of both hands showed low blood flow
1980). A classic paradigm of this theory is the case of in two regions, the thalamus and the basal ganglia.
Anna O., who was treated by Freud (Breuer & Freud, In each individual, subcortical asymmetry involving
1895). Physical symptoms allow for the expression contralateral basal ganglia and thalamic hypo-
of the forbidden wish or urge but also disguise it. activation was present that resolved after recovery.
Other psycho­analytic explanations focus on the need It appears that voluntary commands were blocked
to suffer or identification with a lost object (Ford & from activating the pathways that controlled the
Folks 1985). An analytic therapist would attempt to paralysed arm. The results of this study suggest
treat a conversion disorder by helping the patient that hysterical conversion deficits are maintained
move to more mature defence mechanisms. by a functional disorder of striato-thalamo-cortical

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 Conversion disorder

circuits controlling sensorimotor function and invested heavily in symptoms and have devoted
voluntary behaviour. The basal ganglia, specifically considerable time and resources to helping their
the caudate nucleus, might be particularly well relative deal with their neurological difficulties.
suited to modulating motor processes based on
emotional and situational information from the
limbic system. Hypnosis
Marshall et al (1997) similarly reported on a The similarities between hysteria, hypnosis and
woman with left-sided paralysis (without sensory conversion disorder were noted during the 19th
loss) in whom no organic lesion could be found. century. There is evidence that people with
They measured cerebral blood flow when she tried conversion disorder have above average levels
to move either her paralysed leg or her other leg. of hypnotisability, making hypnosis a potential
The attempt to move the paralysed leg failed to intervention in the management of the disorder (Van
activate the right primary motor cortex. Instead Dyck & Hoogduin, 1989). The goals of such hypnosis
there was activation of the right orbitofrontal and include symptom reduction and exploration. Acting
right anterior cingulate gyrus. This activity might through the evocation of a trance-like state, which
have inhibited prefrontal (willed) effects on the right promotes suggestibility, hypnosis may be effective
primary motor cortex when the woman attempted against symptoms that are influenced by suggestion.
to move the paralysed leg. Hypnosis can also be used to evoke memories of
These two studies suggest that inhibition of willed a traumatic event that has a positive link with the
movement may play an important role in people symptoms.
with functional paralysis. Although there are many anecdotal accounts of
the efficacy of hypnosis in conversion disorder, a
recent randomised controlled trial of the addition of
Management hypnosis to a comprehensive treatment programme
for in-patients with the disorder found that it had
It is crucial in any approach to patients with
no additional effect on treatment outcome (Moene
conversion disorder to establish a therapeutic
et al, 2002).
alliance and to allow recovery with dignity and
without loss of face. It is important that nursing
and medical staff avoid labelling these individuals Prognosis
as manipulative, dependent or as exaggerating their
difficulties. Some 40 years ago Elliott Slater (1965) reported a
10-year follow-up study of patients admitted with
Explanation and psychotherapy conversion symptoms to the National Hospital for
Nervous Diseases, London. He found that over half
Conversion symptoms, especially when acute, had developed clear-cut neurological or psychiatric
may undergo spontaneous resolution following conditions at follow-up. Since that time, several
explanation and suggestion. Some patients respond more follow-up studies have suggested an increased
to active rehabilitation (Teasell & Shapiro, 1994). prevalence of neurological disorder in those with
Those with chronic and entrenched conversion a diagnosis of hysteria or conversion disorder
symptoms may require admission to a psychiatric (Couprie et al, 1995; Mace & Trimble, 1996). Others,
unit that has expertise in conversion disorder. however, have failed to show this relationship.
Such individuals may undergo psychiatric decom­ Crimlisk et al (1998), for example, investigated the
pensation as their symptoms improve, revealing psychiatric and neurological morbidity, diagnostic
depression or even previously hidden psychosis stability and indicators of prognosis in patients
(Hurwitz & Kosaka, 2001). identified 6 years previously as having medically
It may be helpful to explain to patients that unexplained motor symptoms. Unlike Slater, they
sensori­motor disturbances can result from loss of found that a low level of physical and psychiatric
conscious control over the affected function caused diagnoses emerged to explain these individuals’
by a neurochemical disturbance, usually depression, symptoms or disability. Nevertheless, there was a
thereby providing a cognitive framework for high level of psychiatric comorbidity. Crimlisk et al
treatment. Cognitive–behavioural work should be also emphasised that reinvestigation of people with
combined with physiotherapy and any pharmaco­­ conversion disorder is expensive and can put them
therapy necessary for an underlying psychiatric at unnecessary risk from complications associated
disorder. Some clinicians offer abreaction to those with diagnostic procedures.
with deeply entrenched symptoms. Many patients The discrepancy between the high rates of
require family therapy, since families have often neurological disorders reported in some studies

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Owens & Dein

and the lower rates reported in others may arise clearly required to examine prevalence in various
from methodological issues, particularly problems patient groups and to study the efficacy of different
with data analysis in the former group. Ron (2001), modes of treatment for this disorder.
for example, points out how Slater ’s analysis
is flawed and his conclusion, that hysteria is a References
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Slater, E. (1965) Diagnosis of hysteria. BMJ, 1, 1395–1399. 3 In terms of prognosis:

Stephansson, J. G., Messina, J. A. & Meyerowitz, S. (1976) a� spontaneous recovery is rare
Hysterical neurosis, conversion type: clinical and epidemio­
b� chronicity may result in contractures
logical considerations. Acta Psychiatrica Scandinavica, 53,
119–138. c� there is a significantly increased prevalence of major
Teasell, R. W. & Shapiro, A. P. (1994) Strategic-behavioral neurological disorders
intervention in the treatment of chronic nonorganic motor d� there is evidence that rates of suicide are increased
disorders. American Journal of Physical Medicine and Rehabilitation, e� there may be underlying affective or psychotic
73, 44–50.
Tseng, W. (2001) Handbook of Cultural Psychiatry. San Diego, CA: illness.
Academic Press
Van Dyck, R. & Hoogduin, K. (1989) Hypnosis and conversion 4 The following have been used to treat conversion
disorders. American Journal of Psychotherapy, 43, 480–493. disorder:
Vuilleumier, P., Chicherio, C. & Assal, F. (2001) Functional a� hypnosis
neuroanatomical correlates of hysterical sensorimotor loss. b� abreaction
Brain, 124, 1077–1090.
World Health Organization (1992) The International Statistical c� antidepressants
Classification of Diseases and Related Health Problems, Tenth d� cognitive–behavioural therapy
Revision (ICD–10). Geneva: WHO. e� systemic family therapy.

5 As regards the prevalence of conversion disorder:

MCQs a� prevalence in Western countries has increased over
recent years
1 In conversion disorder: b� they are well recognised in young children
a� symptoms may be intentionally produced c� they are more common in men
b� there may be more than one physical symptom d� they are more common in less educated populations
c� symptoms may involve the autonomic nervous e� they are more common in lower socio-economic
system classes.
d� symptoms may not conform to specific dermatomes/
myotomes
e� organic pathology can readily be excluded.

2 Regarding the classification of conversion disorder:

a� in DSM–IV, conversion disorder is in the same category MCQ answers
as dissociative disorders
1 2 3 4 5
b� in ICD–10, conversion disorder is in the same category
as somatoform disorders
a F a F a F a T a F
c� in ICD–10, there is no single distinct entity of b T b F b T b T b F
conversion disorder c F c T c F c T c F
d� conversion disorder was previouly categorised as a d T d T d F d T d T
hysterical neurosis e F e F e T e T e T
e� classification is based on presumed aetiology.

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