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.

In July 2004, Lisa fled domestic violence with her two-year-old son. . She reported that she left the home after her partner held a knife to her throat. She found it hard to give up her previous lifestyle, including two jobs as a support worker. Lisa began a new, loving relationship and became pregnant. She recalled this as a time that she felt very happy. In 2005, while Lisa was pregnant, her partner was arrested for the attempted murder of his ex-wife. While still pregnant, Lisa had her first seizure, resulting in amnesia for a three year period and left-side weakness. Following the birth of her daughter, Lisa became depressed, had poor mobility and frequent seizures. In December 2005, she experienced her most severe seizure, leading to the admission to a neurological ward. Following discharge, she was referred to the mental health Acute Day Treatment Unit. During this time, Lisa acknowledges that she let her partner “do everything” for her. He left her in April 2006 following a gradual breakdown in the relationship attributed to the pressure of his new role as a carer.

Lisa’s discussion of her relationship with her partner can be linked to evidence which suggests that many patients with conversion disorder derive primary or secondary gain⁽⁶⁾. For example, the conversion symptom may provide primary gain in avoiding immediate distress, and secondary gain in creating the ‘patient role’ from which the patient may derive subsequent benefits^(3).. Although Lisa found it difficult to accept this notion when we reviewed the literature, she recognised that she had unconsciously taken on a strong ‘patient’ role. There is some evidence that such gain may operate as a perpetuating factor for a small number of individuals with NES and other functional neurological symptoms. Examples of secondary gain include an avoidance of responsibility and positive benefits of the role, such as eliciting a caring response from others⁽³¹⁾. Reuber et al found the gain of an ‘illness identity’ to be a perpetuating factor in just over 10% of participants in their study⁽³²⁾. This is a relatively small percentage and thus it is important to emphasise that this may not be a factor for many individuals experiencing PNES. However, it did appear to be relevant to Lisa. Approaching the topic of secondary gain where it is suspected to be relevant must be done sensitively in order to protect the therapeutic relationship. In this situation, discussing some of the available literature proved a useful technique for introducing the notion of secondary gain as a possibility for people who experience PNES in a non-threatening and non-blaming manner.

In many cases, the mechanism underlying the conversion symptoms is never identified, or is speculative⁽⁶⁾. It can be helpful to conceptualise two different levels with regard to the etiological significance of various factors: triggers for individual attacks and also the factors that may predispose, precipitate or maintain the disorder⁽³³⁾. A model of PNES should attempt to account for both. There is no widely agreed model as yet⁽³⁴⁾, although understanding is developing. For example, Baslet⁽³⁵⁾ proposes a conceptual framework that proposes individuals with PNES have a vulnerable cognitive-emotional processing system that can predispose individuals to PNES.

In relation to individual attacks, there is evidence that seizures may occur as a dissociative response to heightened arousal, even in the absence of raised general levels of anxiety. This might be thought of as “panic attack without the panic”^{(31, 33)}. Many patients do not clearly identify stress as a trigger for individual attacks⁽³⁴⁾, but Lisa recognised the role of stress throughout. The mechanism of the seizures was thought largely to be dissociation that served to protect her from unpleasant or frightening emotional arousal, as described by Mellers⁽³⁴⁾. It was hypothesised that Lisa developed an adaptive ability to “switch off” during early experiences of abuse and that her seizures represented a re-emergence of this response when she experienced stressful situations⁽³⁴⁾.

Lisa’s seizure diary indicated several examples of seizures happening during a stressful situation, such as a ‘heated debate’ with her partner. However, there were other situations in which the seizures occurred without an apparent trigger other than tiredness. Tiredness could be viewed as a particular form of stress. Alternatively, it could be hypothesised that when Lisa was tired, she was more likely to experience fleeting stressful or unpleasant thoughts that she was barely aware of and had little to do with her immediate circumstances⁽³⁴⁾, but which raised her level of psychophysiological arousal to the extent that a dissociative seizure was triggered⁽³³⁾.

Lisa’s history included a high occurrence of factors associated with conversion symptoms. Through a combination of psycho-education about conversion disorder and a cognitive-behavioural formulation, we identified a number of possible contributory factors in Lisa’s case, outlined below.

• Childhood dominated by alleged criticism from other family members, particularly relating to size and intelligence.

• Sense of rejection by mother because of gender; parents were foster carers but only fostered boys.

• Alleged sexual abuse perpetrated by half-brother from as early as four years old, until 16 years old.

• Alleged physical abuse by half-brother, included being thrown down the stairs in a suitcase. Half-brother’s explanation for injuries allegedly always believed over Lisa’s explanation.

• Half-brother admitted abusing Lisa’s sisters, but not Lisa.

• Small and often physically ill – under care of paediatricians until 16 years old.

• Lisa alleges that when she disclosed the abuse at 12 years of age, her mother threatened that, if Lisa reported the abuse to the police, her parents would separate and lose their jobs, and it would ‘kill’ her grandmother.

• Not able to see father often as he worked away from home.

‘Being worthless, not important, isolated, actively silenced, shoved about, and not listened to’.
Nobody can be trusted.
Everybody hurts me.
Whenever something good happens, it turns bad.
“How can people talk about Heaven and Hell when all I’ve had is Hell in this world?”

Do not have an opinion.
Do not trust others.
Do not let ‘the real me’ through.
Stay miserable so as not to ‘fall so far’.
Scared to leave depression.
I will give my children a good start in life, and love.

• Miscarriage of first child, at 24 th week of pregnancy.

• Domestic violence in previous marriage, particularly incident in which a knife was held to her throat.

• Hormone treatment to aid conception between 1993 and 2002 – Lisa has questioned whether this had negative physical and emotional effects.

• Partner’s arrest and trial.

A naturalistic study of 30 individuals experiencing non-epileptic seizures sought to identify predisposing, precipitating and perpetuating factors considered related to the seizures⁽³²⁾. In relation to predisposing and precipitating factors, 86.6% had experienced non-sexual trauma, 70% experienced social or family factors, 56.7% experienced bereavement, 30% had experienced sexual trauma and 13.3% had experienced physical health issues. Only 3.3% identified no predisposing or precipitating factors⁽³²⁾. Lisa could be said to have experienced each of these factors as either predisposing or precipitating factors in relation to the onset of PNES.

Incestuous sexual abuse may be associated with an increased risk of conversion disorder⁽¹⁾. Physical abuse in childhood has been associated with a larger amount of psychogenic symptoms^{(36, 37)}, and bodily threat has been found to best predict somatoform dissociation⁽³⁸⁾. Family factors seen in Lisa’s case have been linked to conversion disorder, including a lack of family cohesion⁽³⁹⁾ and low perception of maternal care⁽⁸⁾.

A high prevalence of adverse childhood experiences has been found to have a strong, graded relationship with high somatoform dissociation. In this case, these factors are combined with adverse later life events, thus supportive of the assertion that traditional unifactorial trauma-theories of conversion disorder should be replaced by multifactorial stress models⁽⁴⁰⁾.

Reuber et al.⁽²¹⁾ do not distinguish between the perpetuating factors identified among 30 participants with NES and 29 with ‘other’ functional neurological symptoms. However, across the sample of 59, 54.2% identified social or family factors and 42.4% experienced affective disorder thought to perpetuate their symptoms. Both factors were present for Lisa and could be considered as perpetuating factors.

The neurologist at the inpatient unit to where Lisa was admitted referred her to a local neurologist and also to secondary care adult mental health services. This led to her receiving outpatient psychiatric treatment and care from a community Continuing Support Team. The Psychiatrist referred her to the Acute Day Treatment Unit, details of which are outlined below.

The Acute Day Treatment Unit was based within a psychiatric unit. It offered care as an alternative to hospital or following hospital admissions. The Unit was multi-disciplinary and incorporated nurses, technical instructors (who provided group-based art therapy, relaxation and horticultural therapy), physiotherapists, a home economist, a complementary therapist and an assistant psychologist. The unit operated during weekdays and patients had individual care plans of attendance. Lisa attended over a nine-month period, initially for three days per week, gradually reducing to one day per week before discharge.

Lisa had the following goals when she entered treatment: To ‘get better, get rid of fits, get memory back, get on with the children, and go back to work’.

Lisa collaborated with staff at the Acute Day Treatment Unit to create a care plan that would meet her needs. There were eight salient assessed needs that the care plan aimed to address, as follows:

1. Ongoing assessment of needs. Given both Lisa’s mental health and physical health needs, ongoing assessment was a priority. This was particularly true given Lisa’s rapid changes in presentation as she responded to treatment and external influences.

2. Ongoing psychological intervention to work with Lisa regarding her conversion symptoms.

3. To enhance Lisa’s coping skills, both psychological and physical.

4. To both assess and develop Lisa’s active daily living skills.

5. To enhance self-esteem.

6. To develop physical abilities, particularly walking and the use of the left arm and hand.

7. To lift mood and provide distraction from negative thoughts.

8. To explore alternatives to day treatment, and support Lisa in achieving her aims.

Lisa was fully involved in the planning of her care throughout. Below, we outline the various aspects of treatment within the Acute Day Treatment Unit, with Lisa’s comments about each.

A) Acute Day Treatment Unit

i) Group work with the Technical Instructors

ii) Cookery with the Home Economist.

iii) Reflexology and complementary therapy

iv) Physiotherapy

v) Weekly Individual Work with the Assistant Psychologist.

B) Interventions From Other Agencies

i) The Junior Doctor

ii) The Continuing Support Team

iii) Respite care in an ‘Alternative to Hospital Bed’

2) Primary Care Services

A) The General Practitioner (G.P.).

B) The Health Visitor

3) Physical Health Services

A) The Neurologist

B) The outpatient Occupational Therapy department

C) The Physical Disabilities Social Work Team.

4) Family Support Services

A) Children’s (Social) Services

B) Home Care

It would be difficult to believe that the intensive care package Lisa received did not play a significant role in her recovery. It is reasonable to hypothesise that more general characteristics of the care package made a significant contribution to recovery. In line with the suggestion that staff should work to establish a therapeutic alliance and enable recovery with dignity⁽³⁾, the vast majority of staff worked in a genuinely collaborative manner with Lisa. Supportive, insight-oriented, cognitive and behavioural techniques were used to help Lisa develop understanding of her symptoms, consistent with the approach described by Cohen and Chang⁽¹⁴⁾. Lisa was fully involved in developing her care plan and understanding the goals of each treatment. It is thought that this collaborative approach worked by creating environments in which it was safe to change, and in which Lisa was encouraged to replace her symptoms with effective coping strategies. This is in line with the ethos of a process described by Daie and Witzum, who created situations which encouraged individuals to abandon their conversion symptom⁽⁴¹⁾.

Lisa had positive relationships with a number of the professionals involved. Following early life experiences of being actively silenced, Lisa was able to find validation from professionals who took the time to work through her difficulties, as well as intensifying support during ‘crisis’ periods. It is worthy of note that Lisa found treatment most effective when she felt listened to and supported. This is in line with evidence in the literature about the importance of mental health professionals acknowledging symptoms as ‘real’ or ‘genuine’⁽¹³⁾.

Lisa happened to be referred to a unit in which multiple interventions were available for her to access simultaneously. It is acknowledged that the service itself was unusual in a climate of closure for many ‘day services’ in the UK and that many other individuals experiencing PNES may not have access to such a comprehensive package of multidisciplinary care.

It is also important to emphasise that research evidence demonstrates positive outcomes of single interventions, such as specific forms of psychotherapy^{(19, 21)}, suggesting that multiple interventions may not be necessary. In addition, it was not possible to measure the effectiveness of each intervention. It is possible that Lisa would have experienced similar outcomes without receiving such an intense package of treatment, particularly given changes in social circumstances that she experienced during the period of care. However, from both a patient and professional perspective, the multidisciplinary nature of the care package appeared to be highly valuable in addressing each of Lisa’s identified clinical needs.

One of the significant outcomes in Lisa’s case was the improvement that she made in relation to improving her physical ability and overcoming impairments that she had demonstrated on admission. It is hypothesised that work with the physiotherapists and Home Economist, which focused on the development of both gross and fine motor skill tasks, was fundamental in contributing to the positive physical outcomes and a key benefit of a multidisciplinary approach in meeting Lisa’s needs. Further research into outcomes other than seizure frequency might offer further insights into the potential needs and outcomes of those who experience PNES alongside other difficulties, including physical disability, and serve to develop understanding about when a multidisciplinary approach may or may not be either necessary or appropriate.

With the wide range of factors that are thought to contribute to conversion symptoms it must be remembered that, for each patient, there is likely to be a broad contextual background to difficulties as well as a complex presentation of a range of symptoms⁽³⁾. Given this, it is perhaps not surprising that none of the treatment options have yet emerged as an exclusive treatment of choice⁽¹⁶⁾. It seems reasonable to hypothesise that the combination of physical, psychological and pharmacological treatments contributed to Lisa’s recovery. The case seems to offer clinical support to the assertion that cognitive-behavioural work should be combined with physiotherapy, as well as pharmacotherapy⁽³⁾.

Giving Lisa the opportunity to develop a psychological formulation seemed to contribute to her both understanding and regaining control over her experiences. Actively using the available literature on conversion disorder appeared particularly valuable in terms of thinking about possible predisposing and precipitating factors when developing the formulation.

The cognitive framework allowed the conversion symptoms to be viewed as a defensive function that protected Lisa from overwhelming affect⁽⁴⁾. This helped to offer an alternative to the possible view that Lisa’s symptoms were manipulative or exaggerated⁽³⁾. It also helped to directly inform the care plan, as Lisa was supported to recognise situations that were likely to induce overwhelming affect, remove herself from them and practice alternative coping strategies to reduce conversion symptoms. Developing the skills to manage intrapsychic conflict and anxiety⁽⁴⁾ appeared to be fundamental to reducing the frequency of Lisa’s seizures, as well as boosting her confidence and sense of control.

There can be no doubt that Lisa’s own motivation contributed significantly to her recovery. A care package of this intensity would have failed had she not been motivated to fully engage with each of its components. Such care brings with it a certain amount of pressure, and demands a high level of commitment. It is possible that other individuals with similar difficulties may not have the same level of motivation. The implications of this are that working to increase the individual’s motivation may be a valuable investment of time and resources, for example through the use of motivational interviewing⁽⁴²⁾.

External Circumstances and Life Events