Understanding Conversion Disorder: A Condition with Unexplained Physical Symptoms
Neurology • Psychiatry • Rehabilitation
Understanding Conversion Disorder (Functional Neurological Symptom Disorder)
Conversion disorder—now commonly termed functional neurological symptom disorder (FNSD)—produces neurological symptoms (motor, sensory or seizure‑like events) that are inconsistent with recognized neurological disease. Symptoms are involuntary, genuine and can cause significant disability. A clear, compassionate approach combining explanation, rehabilitation and psychotherapy is effective for many patients.
Typical presentations
- Functional motor symptoms: weakness, paralysis, tremor, dystonia or gait disturbance.
- Functional sensory loss: anaesthesia, paraesthesia or non‑anatomical sensory changes.
- Non‑epileptic attack disorder (PNES): paroxysmal events resembling seizures without ictal EEG changes.
- Speech and visual disturbances may also occur (dysphonia, transient visual loss).
Key clinical clues
- Abrupt onset, variability over time, symptoms inconsistent with known neurological pathways, preservation of function in some contexts (e.g., normal automatic movements) and improvement with distraction or suggestion.
- Positive examination signs: Hoover’s sign for weakness, tremor entrainment, inconsistency, and collapsing weakness.
Assessment checklist
- Obtain a detailed history including onset, context (stress or injury), prior medical evaluations and impact on daily life.
- Perform focused neurological exam searching for positive functional signs (Hoover, entrainment, inconsistency) and document findings carefully.
- Use targeted investigations to exclude relevant organic disease: MRI brain/spine, EEG for suspected epileptic seizures, nerve conduction studies where neuropathy suspected. Avoid excessive testing once functional features are clear and no red flags.
- Assess psychiatric comorbidity (anxiety, depression, PTSD), trauma history, and psychosocial stressors; evaluate risk (self‑harm, safety concerns).
How to explain the diagnosis
- Use empathic, non‑stigmatizing language: “Your symptoms are real. The tests don’t show damage to the nervous system, which is actually good news — your nervous system is reversible and responsive to treatment.”
- Provide a brief biopsychosocial formulation: predisposing factors (vulnerability), precipitating events (injury, stress), and maintaining processes (avoidance, unhelpful beliefs).
- Offer a clear plan focused on symptom management, rehabilitation and psychological treatment rather than implying symptoms are “all in the head.”
Treatment components
- Physiotherapy/Occupational therapy: functional retraining using graded activity, distraction techniques, and goal‑directed rehabilitation rather than impairment‑focused therapy.
- Psychological therapy: CBT tailored to FNSD, trauma‑focused therapy where PTSD present, and specific CBT interventions for PNES (CBT‑PNES) to reduce event frequency.
- Integrated MDT care: coordinate neurology, psychiatry/psychology, physiotherapy and primary care to deliver consistent messages and a unified treatment plan.
- Medication: treat comorbid depression or anxiety with antidepressants; no medications directly treat functional symptoms but may help comorbidities that maintain symptoms.
Rehabilitation approach — practical tips
- Set concrete functional goals (e.g., walk 10 minutes without assistance), use graded exposure and daily activity schedules, and avoid excessive emphasis on symptom elimination as an immediate outcome.
- Encourage return to normal activities and work as tolerated; liaise with employers for graded return and reasonable adjustments.
- Use short, frequent physiotherapy sessions with clear tasks and positive reinforcement for achievement.
Managing PNES specifically
- Confirm diagnosis with video‑EEG when available. Provide an explicit, compassionate explanation and safety advice (avoid driving until advised, prevent injury during events).
- CBT for PNES targets seizure‑triggering factors, avoidance behaviours and teaches grounding and seizure‑management strategies; group therapy can be effective.
- Avoid abrupt withdrawal of antiepileptic drugs unless epilepsy definitively excluded—coordinate with neurology.
When to re‑evaluate / red flags
- Progressive focal neurological signs, systemic features, rapidly progressive course, or features suggesting structural disease—urgent neurological review and investigation required.
- Severe psychiatric risk (active suicidal ideation), inability to care for self, or deterioration despite appropriate MDT care—consider inpatient admission and psychiatric input.
Case vignette
Patient: J., 29, developed sudden right leg weakness after a minor ankle sprain with normal MRI and inconsistent exam (positive Hoover’s sign). Management: explain functional diagnosis, initiate physiotherapy with graded walking targets, offer CBT to address fear‑avoidance beliefs and recent relationship stress, and liaise with employer for graded return to work. At 12 weeks J. regained independent mobility and reduced healthcare visits.
தமிழில் — சுருக்கம்
Conversion disorder (functional neurological symptom disorder) என்பது நரம்பு முறையில் அடையாளமான ஆனால் மருத்துவ ரீதியில் விளக்கமில்லாத அறிகுறிகளை உருவாக்கும் ஒரு நிலை. தெளிவான விளக்கம், திறம்பட உடற்பயிற்சி மற்றும் உளவியல் சிகிச்சை அதிக உதவியாகும்.
Key takeaways
- Recognise positive clinical signs of functional disorders and use targeted investigations to exclude organic disease without excessive testing.
- Explain the diagnosis compassionately, set functional goals, and provide integrated rehabilitation plus psychological therapy through an MDT.
- Escalate promptly if red flags for organic disease or psychiatric risk are present; coordinate care and maintain consistent messaging across teams.