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Conversion disorders: Psychiatric and psychotherapeutic aspects Psychiatrie et psychothérapie de l’hystérie O. Cottencin Department of psychiatry and addiction medicine, hôpital Fontan 2, university hospital of Lille, university Lille 2, CHU of Lille, 1, rue Verhaeghe, 59037 Lille cedex, France Received 23 May 2013; accepted 29 September 2013
KEYWORDS Hysteria; Conversion disorder; Somatoform disorder; Psychotherapy; Treatment; Consultation-liaison psychiatry; Combined medical and psychiatric consultation
MOTS CLÉS Hystérie ; Troubles conversifs ; Troubles somatoformes ; Psychothérapie ; Traitement ;
Summary Hysteria is still stigmatized and frequently associated with lying or malingering. However, conversion disorder is not malingering, nor factitious disorder. The first step for the clinician faced with suspected conversion disorder is to make a positive diagnosis, which is in fact an integral part of treatment. In the emergency situation, it is important to look for an underlying somatic disorder. Although no specific treatment exists, there is a consensus in favor of a positive role of psychotherapy. First of all, the main problem is to explain to patients that their physical complaint has a psychological cause. In order to deliver the diagnosis in the most appropriate and useful manner, physicians have to first convince themselves before trying to convince patients. Combined consultation (medicine and psychiatry) is a useful tool to help patients. With or without combined consultation, this approach requires patience and open-mindedness to motivate patients to recognize the value of psychotherapy. Coordination between specialists and general practitioners is an important part of this treatment, which frequently requires long-term intervention. © 2013 Elsevier Masson SAS. All rights reserved. Résumé On continue régulièrement à stigmatiser l’hystérie en tant que tableau fréquemment associé au mensonge ou à la simulation. Or, les désordres conversifs ne sont ni de la simulation ni des désordres feints. La première étape pour le clinicien confronté à une suspicion de conversion est de poser un diagnostic positif, ce qui constitue en fait une partie intégrante du traitement. En situation d’urgence, il est évidemment essentiel d’exclure un problème somatique sous-jacent. Bien qu’il n’y ait aucun traitement spécifique, il existe un consensus d’opinion en faveur du rôle positif de la psychothérapie. D’abord et avant tout, le premier problème est d’expliquer au patient que ses plaintes physiques sont d’origine psychologique. Afin de pouvoir transmettre ce diagnostic de la manière la plus appropriée et convaincante, le médecin doit
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Psychiatrie de liaison ; Multidisciplinarité médecine psychiatrie
en être personnellement convaincu avant d’essayer de convaincre le patient. Une consultation combinée (médecine et psychiatrie) peut constituer un outil utile d’aide au patient. Que la consultation soit ou non organisée de manière combinée, l’approche requiert beaucoup de patience et d’ouverture d’esprit afin de motiver le patient à reconnaître la valeur de la psychothérapie. Une coordination entre les spécialistes et les médecins généralistes est essentielle en vue de ce traitement qui demande régulièrement une prise en charge au long cours. © 2013 Elsevier Masson SAS. Tous droits réservés.
Introduction Hysteria is still stigmatized, being frequently associated with lying or malingering. However, precise definitions have long existed, but these still generally fail to overcome the a priori assumptions of doctors, other paraclinical personnel and patients’ families (as well as those of the general population). Conversion disorder is not equivalent to malingering, whose symptoms and motivation are conscious, nor to factitious disorder, whose symptoms are conscious but in which motivation is unconscious. In conversion disorder, production of symptoms and motivation are unconscious phenomena and benefits are both primary (being an attempt to resolve feelings of anguish) and secondary (with a function of patient protection, but also a powerful reinforcement of symptoms) as summarized by Zumbrummen [22] (see Table 1). These definitions are an indispensable prerequisite for practice, since a good definition of conversion disorders (i.e., medical or neurological definition) involved in the diagnostic process is inextricable from the treatment process. Those definitions have also been confirmed in the diagnostic and statistical manual for psychiatry in which conversion disorder is classified as a subtype of somatoform disorders [2]. The therapeutic process from the doctor’s point of view can be summarized in three parts: • make the diagnosis and be convinced of it; • announce the diagnosis to the patient; • and help the patient to engage in psychotherapy. The first therapeutic step when faced with suspected conversion disorder involves active search for any physical illness. In contrast to what was previously suspected, according to Slater and Glithero’s works [18], in which organic disease was finally discovered in 2 cases of 3 at 10-year follow-up. Stone et al. [20] showed in fact that diagnostic error rate decreased with time. However, the authors’ explanation is that improvement of diagnosis is less connected to advances in medicine (such as development of neuroimaging) than the improvement of the study methodology and evaluation criteria. Thus, the current misdiagnosis rate of conversion disorder stands at 4%, comparable to the misdiagnosis’ rate for schizophrenia (8%) [20]. Therefore, for any suspicion of conversion disorder, the first therapeutic step involves active search for a physical illness. This is particularly true for patients seen in the emergency department, since the cultural and social
plasticity of hysteria means that virtually any form of clinical presentation may be seen. On the other hand, since the diagnosis of conversion disorder is based on clear-cut positive arguments, further researches toward a presumed organic disease can be seen as unnecessary, or rather deleterious. In fact, before the diagnosis of conversion disorder has been established, a so-called ‘‘physical illness’’ should first be investigated, but as soon as the diagnosis of conversion disorder is established, there is no need for further diagnostic tests. Multiplicity of additional tests may have iatrogenic consequences particularly because of ‘‘medical nomadism’’. For example, we report the case of a patient suffering from chronic chest pain who presented with radiation-induced coronary artery disease due to multiple coronary angiographies performed acutely in different hospitals over many years. Psychiatric evaluation must also be alert to the possibility of medico-psychiatric involvement. Indeed, neurolupus may present with psychiatric clinical signs (malignant catatonia, psychotic depression), which could prove lethal if not detected and appropriately treated. Thus, we insist on the importance of good collaboration between physicians and psychiatrists to provide recognition of the unity of symptomatology. Acceptance of the diagnosis is a critical outcome predictor [5].
Diagnosis of conversion disorder Diagnosis of conversion disorder is very difficult. First of all, the physician must beware of overconfidence in his (her) own judgment and symptoms that seem to fit ‘‘too nicely’’. Stone et al. [20] reported 4% false positives and found a combination of a conversion disorder with a somatic disorder in 10 to 25% of cases (raising the interesting question of whether people are good at imitating what they have). In other words, everything that is strange is not necessarily psychogenic. As long as the diagnosis appears unsure to the patient, improvement of symptoms will be delayed. A careful distinction must be made between: • an unusual, somewhat ‘‘strange’’ clinical presentation that deserves full ‘‘somatic’’ investigations, and: • established conversion disorder where there is less need to embark upon extensive examination. For example, we report the case of a patient presenting with theatrical and histrionic symptoms who was admitted to the emergency department with protraction of her tongue and unexplained tremors; this turned out to be due to serotoninergic syndrome secondary to fluoxetine treatment
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Conversion disorders: Psychiatric and psychotherapeutic aspects Table 1
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Differences between somatic disease, somatoform disorder, factitious disorder and malingering.
Subjective symptoms Objective symptoms Voluntary Benefits
Somatic disease
Somatoform disorder
Factitious disorder
Malingering
+ + − ?
+ − − Internal External
+ (+) + Internal
+ − + External
From Zumbrunnen R, Psychiatrie de liaison, Masson ed., Paris, 1991.
(recently introduced to treat a depressive disorder), which improved with 4 mg of lorazepam. However, there are also false negatives, most often related to reluctance of the treating physician to give a firm diagnosis, perhaps due to the worry of missing a somatic disorder; the need to search for typical organic symptoms (supposedly not imitable); and even difficulty in delivering a psychosomatic diagnosis for fear of being unable to handle outcome and treatment. Thus, conversion disorder is a very difficult diagnosis, which sometimes requires several clinical examinations, several experts and a lot of time, but few additional tests, despite the interest of using modern electrophysiology, functional MRI or new neuroscientific technologies. Indeed, conversion disorder should ideally be a positive diagnosis and not one of elimination, in order to have the clearest medical attitude, which helps to prevent an iatrogenic downward spiral. It is important to search for other psychiatric comorbidities. In fact, in this domain (somatoform disorders), it is the rule rather than the exception for patients to have several psychiatric diagnoses. Most studies have found associated depressive disorders [4,9], anxiety disorders [12,21], post-traumatic stress disorder [5] or other somatoform disorders, in variable proportion. In this regard, we note that the presence of a comorbid psychiatric disorder may be a useful therapeutic lever to prepare the consultation with the psychiatrist and even allows avoidance of speaking about the psychogenic disorder (a feature that is often rejected by the patient). However, since diagnosis is an integral part of treatment, it may sometimes be useful to use a functional neuroanatomical basis for explaining the link between psychological and physical symptoms. Thus, it has been found in functional MRI, despite a lack of clear pattern (low and heterogeneous population) [3] that regions involved in dissociative disorders were different from those involved in malingering for similar symptoms [7]. Thus, involvement of cingulate cortex and the ventromedial prefrontal cortex (emotional regulation and self-representation) in dissociative disorders [3,10] can provide scientific validity that could help patient to confirm the existence of their diagnosis and avoid the soma/psyche dichotomy. How to announce the diagnosis is a problem. Most of the time, announcement of the diagnosis is rather catastrophic, which can be summarized (and translated) as follows: ‘‘There is nothing wrong with you, it is all in your head. . . You must go and see a psychiatrist’’. This of course gives the message that the psychiatrist is a specialist of. . . nothing! [16]. The physician must first of all give a clear explanation
of the nature of the diagnosis and reassure the patient about the absence of somatic disorders [5,8,14,17]. However, even if the diagnosis is delivered with tact and prudence, a simple reassurance and affirmation of a non-somatic disorder can have a mixed effect on the patient. Indeed, on one hand the patient feels physical symptoms although the physician tells him about a mental disorder; moreover, patients with psychosomatic disorders (by definition) have limited access to their ‘‘mental’’ level of functioning. Thus without proper precaution, the patient will reject the psychogenic hypothesis, will feel angry (with the feeling of having been misunderstood) and eventually abandon treatment (causing potential medical nomadism). This is because, when the question of psychological suffering comes up ahead of physical symptoms, we usually notice that patients are not prepared to understand (accept) a psychosomatic diagnosis. Patients often feel abandoned (indeed even unwanted), or as if they feigned an illness (‘‘There is nothing wrong with you, it is all in your head. . . you must go and see a psychiatrist’’). Patients cannot easily talk to doctors about their beliefs such as separation between soma and psyche or links between life events and somatic diseases [13], and patients are often not understood when trying to give a meaning to their suffering despite their illness. This attempt to reclaim meaning must always be supervised by physicians.
Psychotherapy: advantage of combined consultations Combined consultation is a consultation that takes place with the simultaneous presence of a physician and a psychiatrist to accompany the patient in the process of investigation, announcement of diagnosis and even treatment plan [8]. This consultation concerns mainly outpatients and can be carried out either in the emergency department or the medical unit with the liaison psychiatry team. In our own practice, we include three steps in these consultations [8]. The first step is an ordinary medical (or neurological) consultation, in which the physician explains the problem to the patient, including discussion of specific symptoms that the doctor does not understand from a biological point of view, and why psychiatric help is required in order to find a better solution for the patient. The patient is then invited to attend a combined consultation with a psychiatrist, so that they might help the patient together. This step is both very important and rather difficult. The physician must warn the patient that they both need the help of a psychiatrist.
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The second step is the combined consultation itself. Firstly, physician and psychiatrist discuss the case together before meeting the patient. Then, physician explains the problem in front of the patient and psychiatrist. The patient can express him/herself and ask questions, during which time the psychiatrist just acts as a mediator. At this point, a change is made from using predominantly medical language to psychopathological language. The psychiatrist then leads the consultation (transition and redefinition of the symptoms). At the end of the combined consultation, the physician and psychiatrist write a joint letter to the general practitioner in front of the patient. The third step follows the combined consultation itself: the physician and psychiatrist discuss and analyze the consultation deciding on what management should be offered to the patient (psychopathological and medical explanations, pragmatic management plans). They also discuss how they felt about the consultation both from objective (i.e., looking for signs of depression) and subjective (the doctor-patient relationship) points of view. Three types of situation have characterized our practice over 1 year of combined medico-psychiatric consultations (100 patients during a 1-year period) [8]: • presence of comorbid psychiatric disorder (57% of consultations); for example, depression that exists concomitantly with cardiac disease or neurological disease and whose evolution is independent. For this situation, we would offer explanations and treatment for both conditions and give an appointment for a psychiatric consultation; • a psychiatric expression of a somatic disorder (2%), such as neurolupus. In this case, we would organize combined medical and psychiatric care; • a somatic expression of a psychiatric disorder (i.e., somatoform disorder) (41%). For example, somatic symptoms such as headache in depression or abdominal pain in somatoform disorder are linked to psychiatric evolution. In those cases, we helped the patient to put his symptoms into words (from soma to psyche) and a psychiatric appointment was given; meanwhile the physician continued to see the patient during the psychiatric follow up period. Combined consultations present many advantages. Firstly, the physician introduces the consultation, meaning that the psychiatrist works together with the physician and facilitates communication with the patient (triangulation: the physician hands on the torch to the psychiatrist). This joint consultation serves several purposes: it allows avoidance of feelings of exclusion or rejection in patients; it allows better initial contact with psychiatry services (increasing the interest in psychopathology and psychotherapy); it helps medical staff understand patients’ beliefs and use them better; it helps explore medical staff’s counter-transference and the doctor—patient relation; and finally the clarification of the diagnosis allows recognition of the patient. As for most consultation liaison psychiatry actions, this consultation can improve prognosis through treatment of comorbid psychiatric disorders, favors compliance, increases the therapeutic alliance with the patient and allows a pragmatic psychiatric or psychotherapeutic
intervention in which the internist takes an interest and which allows a future thought about psychopathology. The psychiatrist, acting as a neutral mediator to whom the situation must be explained by the patient and the physician, helps each to formulate and express a description of the problem; this process allows exploration of new explanations for the patient’s symptoms (other than only the biological hypothesis). On the other hand, combined consultation could present also some disadvantages, in terms of paradoxical accentuation of the soma-psyche dichotomy (two doctors = two distinct fields). Perhaps sequential consultations could better help some patients, especially if the physician has a good knowledge of medical psychology. Another problem (which certainly exists in the French health service but perhaps also elsewhere) is medico-economic impact, this being poorly recognized since it is not possible to reimburse 2 consultations in France, as well as because the duration of the consultation is too long and because results are not immediately identifiable. In any case, when combined consultation is not possible (for example in the context of private practice, or lack of liaison psychiatry services) sequential consultation (first physician then psychiatrist) is the only possibility. However, the absence of psychiatrist must not prohibit the use of medical psychology of each physician and the questioning should remain the same. As in combined consultation, physician explains the problem to the patient, identifies symptoms that he doesn’t understand from a biological point of view, and why he requires psychiatric help in order to find a better solution for the patient. The difference is that the physician rather than the psychiatrist then has to explain how links between soma and psyche exist; in this context drawing on a neuro-psycho-immunology model could help. However, the physician should personally know the psychiatrist, in terms of their working style, attitude towards psychosomatic diseases and personality.
How can we help the patient to engage in psychotherapy? With or without combined consultation, helping the patient to engage in psychotherapy is a difficult step that can be facilitated by some basic steps. First, plenty of time should be devoted to listening to patient’s complaints and explanations of his (her) subjective symptoms. It is important for the physician to accept symptom subjectivity and the patient’s feelings, because they are the main driver of access to psychiatric consultation. It is because of the patient’s own beliefs rather than those of the physician that the patient will accept to meet a psychiatrist. In this particular case of psychosomatic diseases, medical paternalism is certainly not required (‘‘doctor-knows-best’’) but rather mutual education and understanding. A second point to facilitate the first consultation with the psychiatrist is for the referring physician to personally know the psychiatrist. The physician should know the psychiatrist’s method, habits and preferences (for example, some psychiatrists particularly like to treat psychosomatic disorders or conversion disorders). Ideally, a phone call to the psychiatrist in front of the patient (or a letter dictated
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Conversion disorders: Psychiatric and psychotherapeutic aspects in front of the patient) explaining the main problems can facilitate a future meeting. The physician can thus avoid the paradoxical situation of treating a patient who does not wish to be treated.
Is there a specific treatment? There is no treatment whose effectiveness is established for dissociative disorders [5]. These patients are clearly seen as a difficult-to-treat population by neurologists as much as psychiatrists [1,6]. A recent review by Rosebush and Mazurek [15] shows that controlled studies of the treatment of conversion disorders are rare, and almost all information about the effectiveness of particular interventions is descriptive and anecdotal. However, comorbid psychiatric disorders are common and require attention. In addition as highlighted throughout this article, an initial treatment hurdle involves overcoming patient anger about being given a psychiatric diagnosis when they consider their problem to be entirely physical [15]. However, there is a consensus that the psychotherapeutic approach is a preferred management option [5,9]. Aybek et al. [3] recommend providing the patient with a multidisciplinary approach tailored to each individual situation. It is important to explain to patients that they have a known disease. Indeed, diagnostic labels have to be not only helpful to doctors but also acceptable to patients and it has been demonstrated that ‘‘functional disorder’’ is a useful and acceptable diagnosis for physical symptoms unexplained by disease, while ‘‘medically unexplained’’ (which is scientifically neutral) has negative connotations for patients [19]. Thus, most experts recommend engaging patients in a long-term therapeutic strategy that involves at least two specialists (for example neurologist and psychiatrist), and letting general practitioners coordinate all therapeutic actions (which may be numerous) [3]. Of course, the main goal of psychotherapy is to reduce the symptoms of conversion. Classically, therapy can start with awareness of the normal functioning of the body element deemed ill. However, any psychotherapeutic method that allows psychological improvement must be used. Those methods could be focused on conversion symptoms (suggestion, hypnosis, relaxation, eye movement desensitization and reprocessing [EMDR]) or could involve general and psychodynamic methods (psychoanalysis). Although adjuvant treatment with hypnosis has shown no specific benefits [11], it is important to remember that the meeting with the psychiatrist is important in itself and could lead to improvement. In addition, psychotherapists (whether psychoanalysts or not) who provide long-term treatment must always assess the patient’s mental state looking for most commonly associated psychiatric comorbidities (mood disorder, anxiety disorders, post-traumatic stress disorder or other somatoform symptoms) [5]. In this case, pharmacological treatment is only recommended in the context of clearly identified psychiatric disorder (such as anxiety, depression or impulsivity). The psychiatrist will identify target symptoms with the patient and will prevent side effects of drugs. However, as in most functional disorders the treatment goal is not to reach complete elimination of all symptoms,
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but better functioning, better quality of life and decrease in the number and intensity of crises [4]. Finally, although Hubschmid et al. [9] suggest that hospitalization in a neurology (or neurophysiology) department must be continued until resolution of the symptom, we agree with Berney [5] that hospitalization must be limited in time because of the risk of disability and/or chronicity. We think that hospitalization should be reserved for cases with an immediate psychiatric risk (acute psychotic episode, suicidal crisis, catatonia, amnesia, etc.) or somatic complications. Rosebush and Mazurek [15] propose some key elements of successful treatment with which we agree: • open-mindedness on the part of the physician, with willingness to reconsider the diagnosis if recovery does not occur as expected with psychiatric intervention; • patient education about mind-body interplay, using common examples such as worsening of tremor with anxiety or impaired athletic performance when confidence has been undermined (what we defined above as the neuro-psychoimmunological explanation); • involvement of allied health professionals such as physiotherapists, occupational therapists, and speech pathologists, when appropriate; • hospitalization, if the patient is severely disabled or lives in a situation that supports disability or sabotages recovery; • attention to the presence of comorbid medical, neurologic, and psychiatric conditions that may have been overlooked or neglected when the diagnosis of conversion disorder was made, or which develop during the course of treatment. In our experience, it is also important take the patient’s symptoms seriously, to give him hope of a return to a normal or improved state, and particularly to enable disappearance of symptoms without ‘‘losing face’’ because — as described above — conversion disorder is not malingering and healing that is over-rapid (miracle healing) is often resented by both patient and environment. Also, during therapy, we have noticed that it is important to reassure the patient, remove all feeling of shame and always ask for feedback (even negative feedback, for example, ‘‘what I like about you is that you do not do therapy’’).
Conclusion In the emergency situation, it is important to look for an underlying somatic disorder. The first step when faced with conversion disorder is to make a positive diagnosis, which is an integral part of treatment. Long-term treatment is not specific, and the priority is to explain to patient that his (her) physical complaint is actually psychological. To prepare optimal announcement of the diagnosis, the physician has first to convince himself (herself) before trying to convince the patient. This is especially true since the goal is not just to convince the patient, but also to motivate the patient to recognize the value of psychotherapy, which requires patience and open-mindedness on the part of the physician and the
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patient. There is no specific treatment for somatoform disorders, treatment is long and difficult and requires good coordination between specialists and general practitioners.
Disclosure of interest Clinical research: Ethypharm, Lundbeck. Symposia and teaching: For Janssen Cilag, Euthérapie, BMS-Otsuka, Bouchara Recordati, Merck Serono, Sanofi Synthelabo, Lundbeck, Pfizer and Reckitt Benckiser.
Acknowledgments Special thanks to Dr Aileen McGonigal for her help in translation.
[9]
[10] [11]
[12]
[13]
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combined medical and psychiatric consultations. J Psychosom Res 2007;63(2):219—20. Hubschmid M, Aybek S, Vingerhoets F, Berney A. Dissociative disorders: neurologists and psychiatrists working together. Rev Med Suisse 2008;4:412—6. Isaac M, Chand PK. Dissociative and conversion disorders: defining boundaries. Curr Opin Psychiatry 2006;19(1):61—6. Moene FC, Spinhoven P, Hoogduin KA, et al. A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychother Psychosom 2002;71:66—76. Mökleby K, Blomhoff S, Malt UF, Dahlström A, Tauböll E, Gjerstad L. Psychiatric comorbidity and hostility in patients with psychogenic nonepileptic seizures compared with somatoform disorders and healthy controls. Epilepsia 2002;43(2): 193—8. Morell-Dubois S, Carpentier O, Cottencin O, Queyrel V, Hachulla E, Hatron PY, et al. Stressful life events and pemphigus. Dermatology 2008;216(2):104—8. Reuber M, Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav 2003;4(3):205—16. Rosebush PI, Mazurek MF. Treatment of conversion disorder in the 21st century: have we moved beyond the couch? Curr Treat Options Neurol 2011;13(3):255—66. Serrano JA. De la demande de triangulation à la triangulation de la demande. Ann Med Psychol 1997;155:444—54. Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology 1990;40(5):756—9. Slater ET, Glithero E. A follow-up of patients diagnosed as suffering from ‘‘hysteria’’. J Psychosom Res 1965;9(1):9—13. Stone J, Wojcik W, Durrance D, Carson A, Lewis S, MacKenzie L, et al. What should we say to patients with symptoms unexplained by disease? The ‘‘number needed to offend’’. BMJ 2002;325(7378):1449—50. Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, et al. Systematic review of misdiagnosis of conversion symptoms and ‘‘hysteria’’. BMJ 2005;331(7523):989. Szaflarski JP, Szaflarski M, Hughes C, Ficker DM, Cahill WT, Privitera MD. Psychopathology and quality of life: psychogenic non-epileptic seizures versus epilepsy. Med Sci Monit 2003;9(4):CR113—8. Zumbrunnen R. Psychiatrie de liaison. Paris: Masson ed.; 1991.
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ORIGINAL ARTICLE/ARTICLE ORIGINAL
Conversion disorders: Psychiatric and psychotherapeutic aspects Psychiatrie et psychothérapie de l’hystérie O. Cottencin Department of psychiatry and addiction medicine, hôpital Fontan 2, university hospital of Lille, university Lille 2, CHU of Lille, 1, rue Verhaeghe, 59037 Lille cedex, France Received 23 May 2013; accepted 29 September 2013
KEYWORDS Hysteria; Conversion disorder; Somatoform disorder; Psychotherapy; Treatment; Consultation-liaison psychiatry; Combined medical and psychiatric consultation
MOTS CLÉS Hystérie ; Troubles conversifs ; Troubles somatoformes ; Psychothérapie ; Traitement ;
Summary Hysteria is still stigmatized and frequently associated with lying or malingering. However, conversion disorder is not malingering, nor factitious disorder. The first step for the clinician faced with suspected conversion disorder is to make a positive diagnosis, which is in fact an integral part of treatment. In the emergency situation, it is important to look for an underlying somatic disorder. Although no specific treatment exists, there is a consensus in favor of a positive role of psychotherapy. First of all, the main problem is to explain to patients that their physical complaint has a psychological cause. In order to deliver the diagnosis in the most appropriate and useful manner, physicians have to first convince themselves before trying to convince patients. Combined consultation (medicine and psychiatry) is a useful tool to help patients. With or without combined consultation, this approach requires patience and open-mindedness to motivate patients to recognize the value of psychotherapy. Coordination between specialists and general practitioners is an important part of this treatment, which frequently requires long-term intervention. © 2013 Elsevier Masson SAS. All rights reserved. Résumé On continue régulièrement à stigmatiser l’hystérie en tant que tableau fréquemment associé au mensonge ou à la simulation. Or, les désordres conversifs ne sont ni de la simulation ni des désordres feints. La première étape pour le clinicien confronté à une suspicion de conversion est de poser un diagnostic positif, ce qui constitue en fait une partie intégrante du traitement. En situation d’urgence, il est évidemment essentiel d’exclure un problème somatique sous-jacent. Bien qu’il n’y ait aucun traitement spécifique, il existe un consensus d’opinion en faveur du rôle positif de la psychothérapie. D’abord et avant tout, le premier problème est d’expliquer au patient que ses plaintes physiques sont d’origine psychologique. Afin de pouvoir transmettre ce diagnostic de la manière la plus appropriée et convaincante, le médecin doit
E-mail address: [email protected] 0987-7053/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.neucli.2013.09.005
Please cite this article in press as: Cottencin O. Conversion disorders: Psychiatric and psychotherapeutic aspects. Neurophysiologie Clinique/Clinical Neurophysiology (2014), http://dx.doi.org/10.1016/j.neucli.2013.09.005
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O. Cottencin
Psychiatrie de liaison ; Multidisciplinarité médecine psychiatrie
en être personnellement convaincu avant d’essayer de convaincre le patient. Une consultation combinée (médecine et psychiatrie) peut constituer un outil utile d’aide au patient. Que la consultation soit ou non organisée de manière combinée, l’approche requiert beaucoup de patience et d’ouverture d’esprit afin de motiver le patient à reconnaître la valeur de la psychothérapie. Une coordination entre les spécialistes et les médecins généralistes est essentielle en vue de ce traitement qui demande régulièrement une prise en charge au long cours. © 2013 Elsevier Masson SAS. Tous droits réservés.
Introduction Hysteria is still stigmatized, being frequently associated with lying or malingering. However, precise definitions have long existed, but these still generally fail to overcome the a priori assumptions of doctors, other paraclinical personnel and patients’ families (as well as those of the general population). Conversion disorder is not equivalent to malingering, whose symptoms and motivation are conscious, nor to factitious disorder, whose symptoms are conscious but in which motivation is unconscious. In conversion disorder, production of symptoms and motivation are unconscious phenomena and benefits are both primary (being an attempt to resolve feelings of anguish) and secondary (with a function of patient protection, but also a powerful reinforcement of symptoms) as summarized by Zumbrummen [22] (see Table 1). These definitions are an indispensable prerequisite for practice, since a good definition of conversion disorders (i.e., medical or neurological definition) involved in the diagnostic process is inextricable from the treatment process. Those definitions have also been confirmed in the diagnostic and statistical manual for psychiatry in which conversion disorder is classified as a subtype of somatoform disorders [2]. The therapeutic process from the doctor’s point of view can be summarized in three parts: • make the diagnosis and be convinced of it; • announce the diagnosis to the patient; • and help the patient to engage in psychotherapy. The first therapeutic step when faced with suspected conversion disorder involves active search for any physical illness. In contrast to what was previously suspected, according to Slater and Glithero’s works [18], in which organic disease was finally discovered in 2 cases of 3 at 10-year follow-up. Stone et al. [20] showed in fact that diagnostic error rate decreased with time. However, the authors’ explanation is that improvement of diagnosis is less connected to advances in medicine (such as development of neuroimaging) than the improvement of the study methodology and evaluation criteria. Thus, the current misdiagnosis rate of conversion disorder stands at 4%, comparable to the misdiagnosis’ rate for schizophrenia (8%) [20]. Therefore, for any suspicion of conversion disorder, the first therapeutic step involves active search for a physical illness. This is particularly true for patients seen in the emergency department, since the cultural and social
plasticity of hysteria means that virtually any form of clinical presentation may be seen. On the other hand, since the diagnosis of conversion disorder is based on clear-cut positive arguments, further researches toward a presumed organic disease can be seen as unnecessary, or rather deleterious. In fact, before the diagnosis of conversion disorder has been established, a so-called ‘‘physical illness’’ should first be investigated, but as soon as the diagnosis of conversion disorder is established, there is no need for further diagnostic tests. Multiplicity of additional tests may have iatrogenic consequences particularly because of ‘‘medical nomadism’’. For example, we report the case of a patient suffering from chronic chest pain who presented with radiation-induced coronary artery disease due to multiple coronary angiographies performed acutely in different hospitals over many years. Psychiatric evaluation must also be alert to the possibility of medico-psychiatric involvement. Indeed, neurolupus may present with psychiatric clinical signs (malignant catatonia, psychotic depression), which could prove lethal if not detected and appropriately treated. Thus, we insist on the importance of good collaboration between physicians and psychiatrists to provide recognition of the unity of symptomatology. Acceptance of the diagnosis is a critical outcome predictor [5].
Diagnosis of conversion disorder Diagnosis of conversion disorder is very difficult. First of all, the physician must beware of overconfidence in his (her) own judgment and symptoms that seem to fit ‘‘too nicely’’. Stone et al. [20] reported 4% false positives and found a combination of a conversion disorder with a somatic disorder in 10 to 25% of cases (raising the interesting question of whether people are good at imitating what they have). In other words, everything that is strange is not necessarily psychogenic. As long as the diagnosis appears unsure to the patient, improvement of symptoms will be delayed. A careful distinction must be made between: • an unusual, somewhat ‘‘strange’’ clinical presentation that deserves full ‘‘somatic’’ investigations, and: • established conversion disorder where there is less need to embark upon extensive examination. For example, we report the case of a patient presenting with theatrical and histrionic symptoms who was admitted to the emergency department with protraction of her tongue and unexplained tremors; this turned out to be due to serotoninergic syndrome secondary to fluoxetine treatment
Please cite this article in press as: Cottencin O. Conversion disorders: Psychiatric and psychotherapeutic aspects. Neurophysiologie Clinique/Clinical Neurophysiology (2014), http://dx.doi.org/10.1016/j.neucli.2013.09.005
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Conversion disorders: Psychiatric and psychotherapeutic aspects Table 1
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Differences between somatic disease, somatoform disorder, factitious disorder and malingering.
Subjective symptoms Objective symptoms Voluntary Benefits
Somatic disease
Somatoform disorder
Factitious disorder
Malingering
+ + − ?
+ − − Internal External
+ (+) + Internal
+ − + External
From Zumbrunnen R, Psychiatrie de liaison, Masson ed., Paris, 1991.
(recently introduced to treat a depressive disorder), which improved with 4 mg of lorazepam. However, there are also false negatives, most often related to reluctance of the treating physician to give a firm diagnosis, perhaps due to the worry of missing a somatic disorder; the need to search for typical organic symptoms (supposedly not imitable); and even difficulty in delivering a psychosomatic diagnosis for fear of being unable to handle outcome and treatment. Thus, conversion disorder is a very difficult diagnosis, which sometimes requires several clinical examinations, several experts and a lot of time, but few additional tests, despite the interest of using modern electrophysiology, functional MRI or new neuroscientific technologies. Indeed, conversion disorder should ideally be a positive diagnosis and not one of elimination, in order to have the clearest medical attitude, which helps to prevent an iatrogenic downward spiral. It is important to search for other psychiatric comorbidities. In fact, in this domain (somatoform disorders), it is the rule rather than the exception for patients to have several psychiatric diagnoses. Most studies have found associated depressive disorders [4,9], anxiety disorders [12,21], post-traumatic stress disorder [5] or other somatoform disorders, in variable proportion. In this regard, we note that the presence of a comorbid psychiatric disorder may be a useful therapeutic lever to prepare the consultation with the psychiatrist and even allows avoidance of speaking about the psychogenic disorder (a feature that is often rejected by the patient). However, since diagnosis is an integral part of treatment, it may sometimes be useful to use a functional neuroanatomical basis for explaining the link between psychological and physical symptoms. Thus, it has been found in functional MRI, despite a lack of clear pattern (low and heterogeneous population) [3] that regions involved in dissociative disorders were different from those involved in malingering for similar symptoms [7]. Thus, involvement of cingulate cortex and the ventromedial prefrontal cortex (emotional regulation and self-representation) in dissociative disorders [3,10] can provide scientific validity that could help patient to confirm the existence of their diagnosis and avoid the soma/psyche dichotomy. How to announce the diagnosis is a problem. Most of the time, announcement of the diagnosis is rather catastrophic, which can be summarized (and translated) as follows: ‘‘There is nothing wrong with you, it is all in your head. . . You must go and see a psychiatrist’’. This of course gives the message that the psychiatrist is a specialist of. . . nothing! [16]. The physician must first of all give a clear explanation
of the nature of the diagnosis and reassure the patient about the absence of somatic disorders [5,8,14,17]. However, even if the diagnosis is delivered with tact and prudence, a simple reassurance and affirmation of a non-somatic disorder can have a mixed effect on the patient. Indeed, on one hand the patient feels physical symptoms although the physician tells him about a mental disorder; moreover, patients with psychosomatic disorders (by definition) have limited access to their ‘‘mental’’ level of functioning. Thus without proper precaution, the patient will reject the psychogenic hypothesis, will feel angry (with the feeling of having been misunderstood) and eventually abandon treatment (causing potential medical nomadism). This is because, when the question of psychological suffering comes up ahead of physical symptoms, we usually notice that patients are not prepared to understand (accept) a psychosomatic diagnosis. Patients often feel abandoned (indeed even unwanted), or as if they feigned an illness (‘‘There is nothing wrong with you, it is all in your head. . . you must go and see a psychiatrist’’). Patients cannot easily talk to doctors about their beliefs such as separation between soma and psyche or links between life events and somatic diseases [13], and patients are often not understood when trying to give a meaning to their suffering despite their illness. This attempt to reclaim meaning must always be supervised by physicians.
Psychotherapy: advantage of combined consultations Combined consultation is a consultation that takes place with the simultaneous presence of a physician and a psychiatrist to accompany the patient in the process of investigation, announcement of diagnosis and even treatment plan [8]. This consultation concerns mainly outpatients and can be carried out either in the emergency department or the medical unit with the liaison psychiatry team. In our own practice, we include three steps in these consultations [8]. The first step is an ordinary medical (or neurological) consultation, in which the physician explains the problem to the patient, including discussion of specific symptoms that the doctor does not understand from a biological point of view, and why psychiatric help is required in order to find a better solution for the patient. The patient is then invited to attend a combined consultation with a psychiatrist, so that they might help the patient together. This step is both very important and rather difficult. The physician must warn the patient that they both need the help of a psychiatrist.
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The second step is the combined consultation itself. Firstly, physician and psychiatrist discuss the case together before meeting the patient. Then, physician explains the problem in front of the patient and psychiatrist. The patient can express him/herself and ask questions, during which time the psychiatrist just acts as a mediator. At this point, a change is made from using predominantly medical language to psychopathological language. The psychiatrist then leads the consultation (transition and redefinition of the symptoms). At the end of the combined consultation, the physician and psychiatrist write a joint letter to the general practitioner in front of the patient. The third step follows the combined consultation itself: the physician and psychiatrist discuss and analyze the consultation deciding on what management should be offered to the patient (psychopathological and medical explanations, pragmatic management plans). They also discuss how they felt about the consultation both from objective (i.e., looking for signs of depression) and subjective (the doctor-patient relationship) points of view. Three types of situation have characterized our practice over 1 year of combined medico-psychiatric consultations (100 patients during a 1-year period) [8]: • presence of comorbid psychiatric disorder (57% of consultations); for example, depression that exists concomitantly with cardiac disease or neurological disease and whose evolution is independent. For this situation, we would offer explanations and treatment for both conditions and give an appointment for a psychiatric consultation; • a psychiatric expression of a somatic disorder (2%), such as neurolupus. In this case, we would organize combined medical and psychiatric care; • a somatic expression of a psychiatric disorder (i.e., somatoform disorder) (41%). For example, somatic symptoms such as headache in depression or abdominal pain in somatoform disorder are linked to psychiatric evolution. In those cases, we helped the patient to put his symptoms into words (from soma to psyche) and a psychiatric appointment was given; meanwhile the physician continued to see the patient during the psychiatric follow up period. Combined consultations present many advantages. Firstly, the physician introduces the consultation, meaning that the psychiatrist works together with the physician and facilitates communication with the patient (triangulation: the physician hands on the torch to the psychiatrist). This joint consultation serves several purposes: it allows avoidance of feelings of exclusion or rejection in patients; it allows better initial contact with psychiatry services (increasing the interest in psychopathology and psychotherapy); it helps medical staff understand patients’ beliefs and use them better; it helps explore medical staff’s counter-transference and the doctor—patient relation; and finally the clarification of the diagnosis allows recognition of the patient. As for most consultation liaison psychiatry actions, this consultation can improve prognosis through treatment of comorbid psychiatric disorders, favors compliance, increases the therapeutic alliance with the patient and allows a pragmatic psychiatric or psychotherapeutic
intervention in which the internist takes an interest and which allows a future thought about psychopathology. The psychiatrist, acting as a neutral mediator to whom the situation must be explained by the patient and the physician, helps each to formulate and express a description of the problem; this process allows exploration of new explanations for the patient’s symptoms (other than only the biological hypothesis). On the other hand, combined consultation could present also some disadvantages, in terms of paradoxical accentuation of the soma-psyche dichotomy (two doctors = two distinct fields). Perhaps sequential consultations could better help some patients, especially if the physician has a good knowledge of medical psychology. Another problem (which certainly exists in the French health service but perhaps also elsewhere) is medico-economic impact, this being poorly recognized since it is not possible to reimburse 2 consultations in France, as well as because the duration of the consultation is too long and because results are not immediately identifiable. In any case, when combined consultation is not possible (for example in the context of private practice, or lack of liaison psychiatry services) sequential consultation (first physician then psychiatrist) is the only possibility. However, the absence of psychiatrist must not prohibit the use of medical psychology of each physician and the questioning should remain the same. As in combined consultation, physician explains the problem to the patient, identifies symptoms that he doesn’t understand from a biological point of view, and why he requires psychiatric help in order to find a better solution for the patient. The difference is that the physician rather than the psychiatrist then has to explain how links between soma and psyche exist; in this context drawing on a neuro-psycho-immunology model could help. However, the physician should personally know the psychiatrist, in terms of their working style, attitude towards psychosomatic diseases and personality.
How can we help the patient to engage in psychotherapy? With or without combined consultation, helping the patient to engage in psychotherapy is a difficult step that can be facilitated by some basic steps. First, plenty of time should be devoted to listening to patient’s complaints and explanations of his (her) subjective symptoms. It is important for the physician to accept symptom subjectivity and the patient’s feelings, because they are the main driver of access to psychiatric consultation. It is because of the patient’s own beliefs rather than those of the physician that the patient will accept to meet a psychiatrist. In this particular case of psychosomatic diseases, medical paternalism is certainly not required (‘‘doctor-knows-best’’) but rather mutual education and understanding. A second point to facilitate the first consultation with the psychiatrist is for the referring physician to personally know the psychiatrist. The physician should know the psychiatrist’s method, habits and preferences (for example, some psychiatrists particularly like to treat psychosomatic disorders or conversion disorders). Ideally, a phone call to the psychiatrist in front of the patient (or a letter dictated
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Conversion disorders: Psychiatric and psychotherapeutic aspects in front of the patient) explaining the main problems can facilitate a future meeting. The physician can thus avoid the paradoxical situation of treating a patient who does not wish to be treated.
Is there a specific treatment? There is no treatment whose effectiveness is established for dissociative disorders [5]. These patients are clearly seen as a difficult-to-treat population by neurologists as much as psychiatrists [1,6]. A recent review by Rosebush and Mazurek [15] shows that controlled studies of the treatment of conversion disorders are rare, and almost all information about the effectiveness of particular interventions is descriptive and anecdotal. However, comorbid psychiatric disorders are common and require attention. In addition as highlighted throughout this article, an initial treatment hurdle involves overcoming patient anger about being given a psychiatric diagnosis when they consider their problem to be entirely physical [15]. However, there is a consensus that the psychotherapeutic approach is a preferred management option [5,9]. Aybek et al. [3] recommend providing the patient with a multidisciplinary approach tailored to each individual situation. It is important to explain to patients that they have a known disease. Indeed, diagnostic labels have to be not only helpful to doctors but also acceptable to patients and it has been demonstrated that ‘‘functional disorder’’ is a useful and acceptable diagnosis for physical symptoms unexplained by disease, while ‘‘medically unexplained’’ (which is scientifically neutral) has negative connotations for patients [19]. Thus, most experts recommend engaging patients in a long-term therapeutic strategy that involves at least two specialists (for example neurologist and psychiatrist), and letting general practitioners coordinate all therapeutic actions (which may be numerous) [3]. Of course, the main goal of psychotherapy is to reduce the symptoms of conversion. Classically, therapy can start with awareness of the normal functioning of the body element deemed ill. However, any psychotherapeutic method that allows psychological improvement must be used. Those methods could be focused on conversion symptoms (suggestion, hypnosis, relaxation, eye movement desensitization and reprocessing [EMDR]) or could involve general and psychodynamic methods (psychoanalysis). Although adjuvant treatment with hypnosis has shown no specific benefits [11], it is important to remember that the meeting with the psychiatrist is important in itself and could lead to improvement. In addition, psychotherapists (whether psychoanalysts or not) who provide long-term treatment must always assess the patient’s mental state looking for most commonly associated psychiatric comorbidities (mood disorder, anxiety disorders, post-traumatic stress disorder or other somatoform symptoms) [5]. In this case, pharmacological treatment is only recommended in the context of clearly identified psychiatric disorder (such as anxiety, depression or impulsivity). The psychiatrist will identify target symptoms with the patient and will prevent side effects of drugs. However, as in most functional disorders the treatment goal is not to reach complete elimination of all symptoms,
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but better functioning, better quality of life and decrease in the number and intensity of crises [4]. Finally, although Hubschmid et al. [9] suggest that hospitalization in a neurology (or neurophysiology) department must be continued until resolution of the symptom, we agree with Berney [5] that hospitalization must be limited in time because of the risk of disability and/or chronicity. We think that hospitalization should be reserved for cases with an immediate psychiatric risk (acute psychotic episode, suicidal crisis, catatonia, amnesia, etc.) or somatic complications. Rosebush and Mazurek [15] propose some key elements of successful treatment with which we agree: • open-mindedness on the part of the physician, with willingness to reconsider the diagnosis if recovery does not occur as expected with psychiatric intervention; • patient education about mind-body interplay, using common examples such as worsening of tremor with anxiety or impaired athletic performance when confidence has been undermined (what we defined above as the neuro-psychoimmunological explanation); • involvement of allied health professionals such as physiotherapists, occupational therapists, and speech pathologists, when appropriate; • hospitalization, if the patient is severely disabled or lives in a situation that supports disability or sabotages recovery; • attention to the presence of comorbid medical, neurologic, and psychiatric conditions that may have been overlooked or neglected when the diagnosis of conversion disorder was made, or which develop during the course of treatment. In our experience, it is also important take the patient’s symptoms seriously, to give him hope of a return to a normal or improved state, and particularly to enable disappearance of symptoms without ‘‘losing face’’ because — as described above — conversion disorder is not malingering and healing that is over-rapid (miracle healing) is often resented by both patient and environment. Also, during therapy, we have noticed that it is important to reassure the patient, remove all feeling of shame and always ask for feedback (even negative feedback, for example, ‘‘what I like about you is that you do not do therapy’’).
Conclusion In the emergency situation, it is important to look for an underlying somatic disorder. The first step when faced with conversion disorder is to make a positive diagnosis, which is an integral part of treatment. Long-term treatment is not specific, and the priority is to explain to patient that his (her) physical complaint is actually psychological. To prepare optimal announcement of the diagnosis, the physician has first to convince himself (herself) before trying to convince the patient. This is especially true since the goal is not just to convince the patient, but also to motivate the patient to recognize the value of psychotherapy, which requires patience and open-mindedness on the part of the physician and the
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patient. There is no specific treatment for somatoform disorders, treatment is long and difficult and requires good coordination between specialists and general practitioners.
Disclosure of interest Clinical research: Ethypharm, Lundbeck. Symposia and teaching: For Janssen Cilag, Euthérapie, BMS-Otsuka, Bouchara Recordati, Merck Serono, Sanofi Synthelabo, Lundbeck, Pfizer and Reckitt Benckiser.
Acknowledgments Special thanks to Dr Aileen McGonigal for her help in translation.
[9]
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