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Conversion Disorder Case Study With Treatment

Author/s

Whitney Greene, Kayla Foster, Scott Gwinn, Jesse Koerner from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Abstract

In patients diagnosed with conversion disorder, physical therapy can be an important part of a quick recovery from conversion disorder through experiencing improvement in physical function. During physical therapy the focus should be on what the patient is doing correctly and emphasis is placed upon the physical gains of the patient. The patient must be progressively challenged while integrating behavior modifications among functional mobility programs. Research shows the most productive interventions include gait training, strengthening, neuromuscular re-education and balance training, with a full recovery expected for most patients. The patient below exemplifies what may be seen with a patient coming to physical therapy with conversion disorder, as well as expectations and interventions for this patient. [1]

Patient Characteristics

Demographic Information: (occupation/vocation, gender, age, etc.) [2]
• Student
• Female
• 20 years old
• Caucasian

Medical diagnosis if applicable
Diagnosed with Generalized Anxiety Disorder

Co-morbidities
None in medical hx or pt reported

Previous care or treatment
None reported

Examination

Subjective:

Patient History:
A 20 year old female reported to physical therapy with numbness and severe weakness on the left side of her body, specifically her leg. She also complained of moderate low back pain. The patient was recently involved in a bicycle collision with a motor vehicle 3 days ago when she was on her way home from school at a small community college. The patient reports the vehicle clipped the front of her bike while crossing an intersection, causing her to crash hard on her left side. The patient doesn’t remember if she hit her head, but she was wearing a helmet. She only recalls feeling very startled and dizzy after the collision with a couple of scrapes on her left leg from the pavement. The patient was taken to the local, rural hospital to screen for a concussion, which came back negative, where she was then released from the hospital. Since the injury 3 days ago, the patient reports her dizziness has converted to double vision, has difficulty swallowing like there is a lump in her throat, and notices occasional slurred words. Patient continues to have difficulty walking and loss of balance since the accident. Patient reports having increased stress and difficulty completing school work in the past couple of weeks.

Systems Review:[3]

Cardiac
  • Shortness of breath
  • Chest pain

Gastrointestinal

  • Difficulty swallowing
  • Nausea

Musculoskeletal

Neurological

  • Headaches over left eye 
  • Dizziness with standing and gait 
  • Intermittent diplopia
  • Intermittent tinnitus
  • Constant muscle weakness LLE
  • Constant paresthesia in LLE

Urogenital

Medical History: Diagnosed with Generalized Anxiety Disorder 

Chief Complaint:
Difficulty walking and loss of balance 

Prior or Current Services Related to Current Episode: (use relative date days, months, years)
MRI[4], labs, and EMG reports all normal

Self Report Outcome Measures
LEFS: 24/80
FABQw: 37/42
FABQpa: 20/24

Patient Goals: Patient would like to return to riding bike, walking to class without difficulty, and improve her balance.

Objective: Physical Examination Tests and Measures
Patient presented with slurred speech and had difficulty hearing PT during the evaluation. During ambulation, patient presented with a limp on her left side and a decreased gait speed of 1.04 m/sec. Patient also displayed painful facial expressions during LLE MMT.

Physical Exam[3]
Neurological: Inconsistent paresthesia in dermatomes of LLE; patient complains of agitation with wearing long pants
Vitals: Normal
Palpation: No reproduction of symptoms
DTR: Normal
ROM: WNL passively, but difficulty with active full hip & knee ROM while marching in place
MMT: Left quadriceps, hamstrings, gluteal muscle group, dorsiflexors: 4/5

  • Note: During MMT of left quadriceps, hamstring contracted in opposition and vice versa with hamstring MMT
  •  All other muscles on left side and right side: 5/5

Outcome measures[5]

  • 10MWT: 1.04 m/sec (Normative value for female 20 years old: 2.47 m/sec)
  • STS x 5: 14.2 sec (Normative values for 19-49 years old: 6.2 +/- 1.3 sec)

Clinical Impression

Based upon the exam findings, the clinical impression is unclear based on a physical therapy diagnosis. The unusual pattern of signs and symptoms do not follow any musculoskeletal or neurological condition. These inconsistent findings include female gender, unexplained paresthesia and muscle weakness, visual impairments, hearing loss, gait disturbances, slurred speech, and headaches. These signs and symptoms were presented after the patient had a non trivial accident of falling from her bike. Although she was tapped by a car, concussion testing came back negative and she only suffered scrapes on her legs. Based on patient history and inconsistent findings that cannot be explained by an organic or neurological problem would lead the physical therapist to consider conversion disorder. In cases of conversion disorder patients can experience paralysis or parasthesia even when they are not physically harmed enough to cause this impairment.[6] Some of the other possible differential diagnoses, but not limited to, are multiple sclerosis, myasthenia gravis, idiopathic dystonia, system lupus erythematosus, Guillain-Barre, post-encephalitis syndrome, and brain/spinal tumors.[3][7] These, as well as any other possible diagnoses identifying an organic cause for the signs and symptoms, must be ruled out in order to assume the patient is suffering from conversion disorder. It is important that the patient understands that the other tests were negative without confrontation, and that a full recovery can be expected.[3]

Summarization of Examination Findings

The examination findings consist of unexplained pain, paresthesia, and muscle weakness in the LLE, gait disturbances with a limp and decreased gait speed, visual impairments, hearing loss, slurred speech, difficulty swallowing, and headaches. The patient reported poor scores on the LEFS, FABQw and FABQpa; and displayed deficitis in the Berg Balance Scale, 10 Meter Walk test and 5 x Sit-to-Stand test. These unusual patterns of symptoms and objective findings do not follow any specific musculoskeletal or neurological condition, such as radicular symptoms or multiple sclerosis; which lead us to the diagnosis of conversion disorder.

Plan of Care

Intervention

Balance/Coordination:

  • Tandem Stance
  • Balloon Volleyball
  • Wobbleboard

Gait

  • Parallel bars
  • Weight shifts A-P, M-L
  • Gait with obstacles 

LE Strengthening

  • Sit-to-stands
  • 4-way hip with theraband

Phases of Interventions (e.g. protective phase, mobility phase, etc.)

Treatment Progression:
Build Rapport[3]

  • Let the patient know you believe they have a problem 
  • Make the patient want to work with you and take ownership of the problem
  • Reward wanted behaviors and give positive reinforcement
  • Ignore unwanted behaviors, but do not punish for them
  • Emphasize quality over quantity
  • Develop goals in collaboration with the patient
  • Do not focus on their deficits, but focus on their positives
  • Introduce patient to full collaborative team that will be involved in their care

Pre-gait and strengthening[3]

  • Weight shifts
  • Balance
  • Sit-to-stands
  • Transfer training
  • Decrease BOS
  • Dynamic sitting balance
  • Tandem stance
  • Single-leg stance
  • Bed mobility 

Gait[3]

  • Standing and gait in parallel bars
  • Step over obstacles
  • Side-stepping 
  • Retro gait

General Mobility[3]

  • Gait outside of parallel bars
  • Maneuvering obstacles
  • Endurance training
  • Multi-tasking
  • Seated weight shifts

Community Integration[3]

  • Walking outside
  • Curb management
  • Uneven terrain
  • Ascending/descending stairs
  • Navigating architectural barriers
  • Community/job/recreation incorporation
  • Walking while carrying books
  • Discharge planning

Dosage and Parameters

3x per week for 4 weeks 

Rationale for Progression
A patient with conversion disorder needs to see improvements in physical therapy to help the patient believe they are getting better. The progression follows the same progression as for someone with a neurological disease with known origins because research has shown conversion disorder follows similarly to the progression of a neurological disorder. Research further suggests following PT Practice Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling for this diagnosis.[3]

Co-interventions if applicable (e.g. injection therapy, medications)

Pharmaceutical interventions, psychologist, occupation therapy, speech therapy, recreational therapy, nursing[3]

Outcomes

Patient was able to completely recover functionally and integrate back into everyday life with normal gait and balance with abolishment of all prior symptoms. Patient was able to return to school and walk or ride her bike to class. Patient achieved goals of walking, riding bike, no complaint of weakness and integrated back into the social life at her school. She recently made the Dean's list and is now leading the Pre-PT club.


Outcome Measures at Discharge:

  • Berg Balance Scale: 52/56
  • 10MWT: 2.49 m/sec
  • STS x 5: 5.9 sec
  • LEFS: 77/80
  • FABQw: 2/42
  • FABQpa: 1/24

Discussion

Patients diagnosed with conversion disorder may pose as difficult for physical therapists to treat based on the inconsistencies and lack of organic cause for the subjective and objective findings. The present case focused around expected findings with this disorder with an intervention basis derived from a prior rehabilitation model and case series from the literature.[3] [6]Based on the findings, this course of treatment has shown recovery with patients presenting with conversion disorder, however each patient will present in a different manner and a variation of the described symptoms may be present. Thus, this model should be modified to cater to the patient and each treatment should be individualized based on the specific findings patient to patient. Although conversion disorder does not present with a primary cause to need physical therapy, research has shown that when the patient can see their strength and functional gains, it helps them recover quicker psychologically from this disorder. During physical therapy it is important to recognize when the patient becomes fatigued and give them rest breaks or tell them to take time, recover and then try again. The therapist should always provide encouragement and make the patient feel as though they are achieving their functional gains. 

Additional patient case examples of conversion disorder:

Conversion Motor Paralysis Disorder: Overview and Rehabilitation Model
Conversion Disorder Presenting with Neurologic and Respiratory Symptoms
Physical Therapy Management for Conversion Disorder: Case Series

Related Pages

Conversion Disorder Web Page

References

  1. ↑Conversion Disorders. Medscape website. http://emedicine.medscape.com/article/287464-overview. Last updated on June 26, 2013. Accessed on March 10, 2015.
  2. ↑Conversion Disorder Specific Culture, Age, and Gender Features. Recurrent Depression website. http://www.recurrentdepression.com/site/more/111/. Last updated on September 18, 2006. Accessed on March 10, 2015.
  3. 3.003.013.023.033.043.053.063.073.083.093.103.11Ness, D. Physical Therapy Management for Conversion Disorder: Case Series. Journal of Neurologic Physical Therapy. March 2007; 31(1): 30-39. doi: 10.1097/01.NPT.0000260571.77487.14.
  4. ↑Normal Neurodegenerative MRI Protocol. Radiopedia Website.http://radiopaedia.org/images/4935581. Accessed March 26, 2015.
  5. ↑Rehabilitation Measures Database. http://www.rehabmeasures.org/default.aspx. Accessed on March 10, 2015.
  6. 6.06.1Heruti R, Levy A, Adunski A, Ohry A. Conversion motor paralysis disorder: overview and rehabiliation model. Spinal Cord. July 2002;40(7):327-334. Available from: MEDLINE, Ipswich, MA. Accessed March 14, 2015.
  7. ↑Conversion Disorder. Physiopedia Website. www.physio-pedia.com/Conversion_Disorder. Accessed on March 24, 2015.

Conversion disorder is part of the group of somatoform disorders(1), with the DSM-IV criteria as follows(2):

a) One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

b) Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

c) The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

d) The symptoms or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as culturally sanctioned behaviour or experiences.

e) The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

f) The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Conversion has been attributed to many different mechanisms(3), with some of the proposed etiologies including neuroanatomical, psychodynamic with trauma and dissociation, cognitive-behavioural, volitional feigning with conscious or unconscious awareness, communication difficulties and disturbances in the family system(4). Symptoms include amnesia(5), seizures(3) and weakness or even paralysis(6). Some conversion symptoms last hours to days, while others linger or even result in permanent complications, such as disuse contractures of a paralysed limb(5).

Psychogenic nonepileptic seizures (PNES) are one of the common symptoms of conversion disorder(3). They occur in 15% of all conversion patients(6) and are sometimes referred to as ‘dissociative seizures’(7) or ‘pseudoseizures’(8). Clinicians readily admit feeling ill equipped to care for patients with PNES(4), which may contribute to explaining the relative paucity of theoretical papers and treatment trials. However, there has been some recent interest in the treatment of both PNES(4) and conversion disorder more generally(3). Both are relevant to the current case study.

There is some evidence in the literature regarding the possibility that patients with conversion disorder may be viewed as difficult to help and may be subject to pejorative attitudes by clinicians or those around them. For example, neurologists have been found to perceive patients with predominantly unexplained symptoms to be more difficult to help than those whose symptoms were explained by neurological disease(9). Such perceptions are important to consider because of the possibility that they may impact on the interactions between clinicians and patients and ultimately on treatment effectiveness.

Nettleton(10) highlights the context of a society that does not readily grant permission to be ill in the absence of disease. In the United States and United Kingdom, pejorative views may be linked to newspapers’ disparaging use of the term ‘psychosomatic’ to mean an illness that is not important or is imaginary, malingered or representative of a character flaw(11). Stone et al.(11) raise the potentially serious problem of acceptability for those with psychosomatic difficulties. This is reiterated by a study that found negative attitudes towards patients with conversion symptoms on neurology wards were common, albeit not held by the majority of nurses(12). Examples included 46% of the 68 nurses who participated viewing patients as ‘manipulative’ and 16% disagreeing that conversion symptoms were ‘real’(12).

Owens and Dein(3) (p. 155) emphasise the importance of nursing and medical staff avoiding the labelling of individuals diagnosed with conversion disorder ‘as being manipulative, dependent or as exaggerating their difficulties’, in order to establish a therapeutic alliance and enable recovery with dignity. This could be seen as a philosophy that can underpin any approach to the treatment of somebody diagnosed with conversion disorder, regardless of the specific treatment utilised. It is also an approach supported by findings relating to the experience of patients with medically unexplained symptoms, which suggest the importance of friends, family and particularly health professionals acknowledging symptoms as ‘genuine’(10). This is reiterated by the finding that perceptions of doubt from medical professionals, society and even friends and family were reported to contribute to feelings of isolation and distress among those with nonepileptic seizures(13). In addition to evidence from those experiencing NES, recognition of symptoms as ‘genuine’ is also in line with the general acceptance that direct confrontation is an ineffective approach and that ‘more supportive, insight-oriented, cognitive, and behavioural techniques’ are recommended to focus on understanding symptoms within a biopsychosocial framework(14).

There are several treatment options for conversion symptoms. There is some evidence that both suggestive and behavioural therapeutic techniques and eclectic treatment programmes are effective in the treatment of conversion symptoms(15). It must be acknowledged that many patients fail to follow through with, or benefit from, psychological or psychiatric intervention(6). However, although no specific intervention has emerged as the treatment of choice(16), an evidence base is emerging in support of the effectiveness of psychotherapy and variants of cognitive-behavioural therapy are the mainstay of treatment(17). Controlled research into the treatment of conversion symptoms is scarce and can often be criticized on methodological grounds(18), although this is widely acknowledged and randomised controlled trials are now taking place(19).

Howlett and Reuber(20) describe an approach grounded in psychodynamic interpersonal therapy but augmented with elements of cognitive-behavioural therapy, somatic trauma therapy and the involvement of caregivers and family members. They hypothesise that the mechanisms for change are the identification and alternation of problematic interpersonal patterns and the processing of repressed or unrecognised emotions. A pilot study(21) found this approach to be associated with significant improvements in all outcome measures used, which included measures of subjective well-being, symptoms, risk, physical functioning, role limitations due to emotional problems and mental health. Such improvements appeared to be maintained 6 months after the cessation of therapy(21).

Several studies have supported the efficacy of cognitive-behavioural therapy for PNES. A pilot study of the use of 12 sessions of CBT for 20 patients with PNES suggested that those who completed the programme demonstrated a significant reduction in seizure frequency and an improvement in self-rated psychosocial functioning both post-treatment and at six-month follow-up(7). This finding was further supported by a study of a 12 week manualised CBT for PNES study, in which 11 of the 17 individuals who completed reported no seizures by their final session, as well as improvement on scales of depression, anxiety, somatic symptoms, quality of life and psychosocial functioning(22). A later pilot randomised controlled trial(19) compared CBT with standard medical care and found CBT to be superior in leading to seizure reduction at treatment end. In addition, those in the CBT group tended to be more likely to have been free of seizures for three months at six-month follow-up.

In addition to psychotherapy, pharmacological treatments might be used. A recent double-blind, randomised, placebo-controlled trial found that PNES were reduced in patients treated with a serotonin selective reuptake inhibitor. In contrast, those treated with placebo experienced a slight increase in PNES(23). Pharmacological treatments might be used in isolation, or be augmented with psychological treatment, even in the absence of axis I disorders such as depression(17). However, there is little strong evidence available in relation to pharmacological treatments and further research is necessary.

Aside from a small number of articles(14, 20, 24, 25), there is limited literature that describes the treatment of conversion symptoms. The available literature focuses on different aspects or types of treatment, in both inpatient(15) and outpatient settings(25). LaFrance and Barry(4) (p.367) assert that ‘a multidisciplinary approach may provide distinct advantages for treatment’ of PNES. This is supported by a review of nondrug treatments for PNES, which concluded that prognosis is good when management takes place in a specialist unit with a multidisciplinary approach and team familiar with the patient group(18). However, multidisciplinary or multispeciality(26) approaches may comprise a range of treatments. There appears to be a lack of literature that describes a multi-disciplinary approach to outpatient treatment of conversion. There is also an absence in the literature of patients’ perspectives about their experiences of treatment. It is this scarcity that generated the initial motivation to report this case study. Quotations from the patient are included throughout the present case study to explicitly incorporate her perspective. She worked with the first author to record her views in writing for the purposes of the case study and gave written authorisation for these quotes to be included.

The complex needs of an individual with conversion disorder can require a package of care that is multi-agency as well as multi-disciplinary. The descriptive nature of the current study aims to give a more accurate sense of the clinical reality of working with such a case.

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