Conversion motor paralysis disorder.

Hysteria was first documented 4,000 years ago by the Egyptians, who believed the symptoms originated from the uterus, hence the name (hysterus). (1) "Hysterical" conditions included combinations of seizures, paralysis, and anesthesia. During the 17th and 18th centuries, a variety of disorders such as hypochondriasis, hysteria, dyspepsia, and "gas and spleen disease" (vapors) were included under the general heading of "nervous disorder," a term created by Briefe in 1603, that was subsequently replaced with the vague term "nervous temperament." (2) The modern age of nerve pathology commenced in 1843, the year Du Bois Reymond demonstrated electrical conduction in nerves. No electrical disturbances were found in the "nervous temperament," leading to the hypothesis of a psychogenic origin for these disorders. (3) The term "hysterical conversion" was created approximately 100 years before Freud's birth, in an attempt to justify the existence of hysteria as a diagnosis. Lhermitte wrote "hysteria is the mother of deceit and trickery." Babinski defined hysteria as a disease with a psychological etiology, with no clear physiologic or morphologic evidence, and characterized hysteric patients as hyper suggestible and easy to hypnotize. (2,3) Paul Briquet was the first to make an association between conversion disorder and central nervous system disorders during the 19th century. He claimed conversion disorder was due to stress and environmental situations, affecting "affective" areas in the brain of a person with premorbid hypersensitivity. (4) His follower, Charcot, hypothesized that these patients were suffering from a global disorder in the brain, exposing them to the development of conversion disorder. Lately, his work has regained recognition, when the component of his theory concerning the pathophysiology of trauma was introduced into modern theories regarding PTSD and somatoform disorder. (5) Freud, a student of Charcot, defined "La Grande Hysterie," which overlapped the definition of motor paralysis. According to his traumatic model of hysteria, published in 1899, hysterical symptoms stem from sexual trauma, that activates an old traumatic event (Nachtrigli-chkeit). Freud argued that through analysis, the childhood trauma is restored and the neurotic symptoms released via a transfer mechanism. (6) Presently, the term conversion disorder (hysterical neurosis--conversion type) is listed in the DSM-IV (7) under somatoform disorder group (code 300.11), and is described as a psychological disorder, characterized by somatic symptoms with no physiologic abnormalities, but with an underlying psychological basis.

It is important to increase the awareness of the relatively rare phenomenon of motor conversion disorder, as seen in "Conversion Disorder Presenting as Hemiplegia and Hemianesthesia with Loss of Neurologic Reflexes" in this month's Journal. (8) The cumulative experience of a large series of patients with "conversion motor paralysis" who were admitted to the rehabilitation ward was recently published. (9,10) All the patients had neurologic symptoms without any anatomic or physiologic basis. The diagnosis was determined after ruling out organic components or other psychogenic diagnoses. (11) Accurate diagnosis is imperative, as erroneous diagnostic labeling may expose these patients to unnecessary treatments and potential side effects.

Conversion disorder should be differentiated from other disorders. (12) Factitious disorder is characterized by physical or mental symptoms produced voluntarily by the patient, while the unconscious motive is embracing the patient role. There is no evidence of external incentive. With malingering, the motive for producing the symptoms is conscious, and the purpose is prominent with clear secondary gain. The patient has a clear external motive, in contrast to the factitious patient, who is motivated by the mental unconscious need to take on the patient role and receive treatment. Factitious disorder reflects pathophysiology, while malingering reflects adjustment to a certain condition.

Conversion disorder is similar to organic disabilities in that it affects the occupational and social aspects of the patient's life; thus, comprehensive assessment, treatment and rehabilitation should be introduced as early as possible during the course. (10) The interdisciplinary team approach (13) in a rehabilitation center offers distinct advantages in the treatment of conversion disorders. A case manager must direct and coordinate all treatments. In addition to the obvious benefits of a comprehensive approach, the stigma of psychiatric hospitalization is avoided. Treatment should be directed toward the symptoms and as such, the patients should be hospitalized in the correct rehabilitation wards according to their physical symptoms. Treatment in a rehabilitation system should also address the prevention of secondary disabilities.

Of importance is the fact that between 25 to 50% of patients diagnosed with conversion disorder will subsequently be diagnosed with an organic medical condition. (14) This percentage has been lower in recent publications, most probably due to increased awareness to the disorder and advanced diagnostic techniques.

References

1. Ford CV, Folks, DG. Conversion disorders: an overview. Psychosomatics 1985;26:371-383.

2. Hare E. The history of 'nervous disorders' from 1600 to 1840, and a comparison with modern views. Br J Psychiatry 1991;159:37-45.

3. Mace CJ, Hysterical conversion, I: a history. Br J Psychiatry 1992;161:369-377.

4. Mai FM, Mersky H. Briquets concept of hysteria: an historical perspective. Can J Psychiatry 1981;26:57-63.

5. White MB. Jean-Martin Charcot's contributions to the interface between neurology and psychiatry. Can J Neurol Sci 1997;24:254-260.

6. Makari GJ. Dora's hysteria and the maturation of Sigmund Freud's transference theory: a new historical interpretation. J Am Psychoanal Assoc 1997;45:1061-1096.

7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder. Fourth Edition. Washington, DC, American Psychiatric Association, 1994.

8. Hill E, Haydel M. Conversion disorder presenting as hemiplegia and hemianesthesia with loss of neurologic reflexes. South Med J 2006;99:380-382.

9. Heruti RJ, Reznik J, Adunski A, et al. Conversion motor paralysis disorder: analysis of 34 consecutive referrals. Spinal Cord 2002;40:335-340.

10. Heruti RJ, Levy A, Adunski A, Ohry A. Conversion motor paralysis disorder: overview and rehabilitation model. Spinal Cord 2002;40:327-334.

11. Parobek VM. Distinguishing conversion disorder from neurologic impairment. J Neurosci Nurs 1997;29:128-134.

12. Stone J, Zeidler M, Sharpe M. Misdiagnosis of conversion disorder. Am J Psychiatry 2003;160:391-392.

13. Heruti RJ, Ohry A. The rehabilitation team. Am J Phys Med Rehabil 1995;74:466-468.

14. Gould R, Miller BL, Goldberg MA, Benson DF. The validity of hysterical signs and symptoms. J Nerv Ment Dis 1986;174:593-597.

All of us want to do well. But if we do not do good, too then doing well
will never be enough.
--Anna Quindlen

Rafael J Heruti, MD

From the Rehabilitation ward, Reuth Medical Center and the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.

Reprint requests to Rafi Heruti, MD, Rehabilitation ward, Reuth Medical Center, Hachayil 2 Boulevard Tel-Aviv 61092, Israel. Email: [e-mail]

Accepted January 13, 2006.