NEUROLOGY: Teamwork and tact for conversion disorders

In “Is That a Conversion Disorder?” Donald L. Gilbert, MD, FAAP, suggested emphasizing the possibility of functional causes in patients unwilling to consider psychogenic issues, but referring quickly to neurology for multidisciplinary management nonetheless.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies conversion disorder among somatic symptoms and related disorders. A key element for diagnosing conversion disorders-also known as functional neurological disorders-is the presence of signs and symptoms incongruous with a defined disease, as in cases where electroencephalography evidence contradicts that actual seizures are occurring.

Nevertheless, Gilbert said, the loss of physical function (such as blindness or paralysis) that marks a conversion disorder is not faked or "all in the patient's head." With that in mind, he offered practical strategies for diagnosing and treating conversion disorders:

• Consider that minor stressors can seem major for patients with poor coping skills, unresolved emotions, or underlying mood disorders.

• Work with the patient's feelings and/or behavior. This may be more productive than identifying the source of stress.

• Interact with the patient and family tactfully. When delivering a diagnosis, if the family seems open to a diagnosis related to stress or mental health, use psychogenic terminology, such as suggesting that the child's symptoms stem from "pseudoseizures, also known as nonepileptic seizures." If the family is not open to psychogenic causes, steer toward functional terminology, such as ascribing the symptoms to "functional nonepileptic events where the brain sends abnormal signals to the body, producing shaking that resembles seizures."

• When in doubt, refer quickly to neurology for thorough evaluation of possible pseudoseizures, functional movements, and weakness (and avoid the emergency department unless the patient's safety is at risk). Short duration of symptoms, early diagnosis, and patient satisfaction with care bode well prognostically.

Donald L. Gilbert, MD, FAAP, is a professor, University of Cincinnati Department of Pediatrics and Cincinnati Children’s Hospital Medical Center, Ohio.

By the time a patient reaches my office, the family has gone through many evaluations. Their experience is that nothing fits; nothing makes sense. Families tend to be open to some sort of psychogenic cause, mostly because they just want an answer. That's been my experience.

Keep in mind that epilepsy or any other neurologic illness is very complicated, and there can be a psychological component, if you will, to neurologic disease that can be just as complex. If you have epilepsy, it's very common to have depression or anxiety. So sometimes you can treat the epilepsy, but depression remains. The key is that you must treat all aspects of the patient's illness, not just the neurologic aspects.

Many people with nonepileptic seizures also have electrical seizures. That's probably the most common type of person who has nonepileptic events. Sometimes you can try to decipher which events stem from electrical changes versus which do not. Sometimes the patient will have a feeling or a seizure aura that occurs prior to an event and does not develop into a seizure, but it reminds them of a seizure. They will have some sort of nonepileptic event that is similar, just because their brain is sending signals that say "this might be a seizure coming," but in fact it's a nonelectrical event.

Additionally, there's still debate about some of the terminology, at least for the nonepileptic seizures. Some people say things such as "nonelectrical seizures" or "nonepileptic events."

Overall, the key is to have a team approach, that is, a neurologist and a psychiatrist who are experienced with these kinds of illnesses, to work on understanding and categorizing these events-and their precursors-more accurately. Once people know and understand what they're dealing with, they can usually gain some control over it.

Jay Salpekar, MD, is medical director, Neuropsychiatry in Epilepsy Clinical Program, Kennedy Krieger Institute, Baltimore, Maryland.

Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.