Curr Pain Headache Rep (2017) 21:29
DOI 10.1007/s11916-017-0627-7
PSYCHOLOGICAL AND BEHAVIORAL ASPECTS OF HEADACHE AND PAIN (D BUSE, SECTION EDITOR)
Conversion Disorder, Functional Neurological Symptom
Disorder, and Chronic Pain: Comorbidity,
Assessment, and Treatment
Patricia Tsui 1 & Andrew Deptula 2 & Derek Y. Yuan 3
# Springer Science+Business Media New York 2017
Abstract
Purpose of Review This paper examines the overlap of con-
version disorder with chronic pain conditions, describes ways
to assess for conversion disorder, and provides an overview of
evidence-based treatments for conversion disorder and chron-
ic pain, with a focus on conversion symptoms.
Recent Findings Conversion disorder is a significant problem
that warrants further study, given that there are not many well-
established guidelines. Accurate and timely assessment
should help move treatment in a more fruitful direction and
avoid unnecessary medical interventions. Advances in neuro-
imaging may also help further our understanding of conver-
sion disorder. Creating a supportive environment and a col-
laborative treatment relationship and improving understand-
ing of conversion symptoms appear to help individuals diag-
nosed with conversion disorder engage in appropriate treat-
ments. Novel uses of earlier treatments, such as hypnosis and
psychodynamic approaches, could potentially be beneficial
and require a more vigorous and systematic study.
Summary There are treatments that produce significant im-
provements in functioning and reduction of physical symptoms
from conversion disorder even for very severe cases.
This article is part of the Topical Collection on Psychological and
Behavioral Aspects of Headache and Pain
* Patricia Tsui
patricia.tsui@stonybrookmedicine.edu
1
Department of Anesthesiology, Chronic Pain Division Stony Brook
Medicine, 3 Edmund Pellegrino Rd, Stony Brook, NY 11794, USA
2
Department of Psychiatry, Stony Brook University, 101 Nicolls Rd,
Stony Brook, NY 11794, USA
3
Department of Neurology, Health Sciences Center T-12, 020, Stony
Brook Medical Center, Stony Brook, NY 11794, USA
Hypnotherapy, cognitive behavioral therapy, and inpatient mul-
tidisciplinary treatment with intensive physiotherapy for severe
cases have the most evidence to support reduction of symptoms.
Components of treatment for conversion disorder overlap with
treatments for chronic pain and can be used together to produce
therapeutic effects for both conditions. Treatment needs to be
tailored for each individual’s specific symptoms.
Keywords Conversion disorder . Functional neurological
symptom disorder . Psychogenic nonepileptic seizure .
Chronic pain . Somatoform disorder . Medically unexplained
symptoms
Introduction
Conversion disorder (CD) or functional neurological symptom
disorder (FNSD) as defined in the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) [1] involves (1) one or
more symptoms of altered voluntary motor or sensory function;
(2) clinical findings showing incompatibility between the
symptom/s and recognized neurological or medical conditions;
(3) these symptoms or deficits are not better explained by another
medical or mental health disorder; and (4) the symptom/s cause
clinically significant distress or impairment in social, occupation-
al, or other important areas of functioning that warrants medical
attention. The diagnosis of CD was changed to FNSD and the
definition has been updated since the last version of the DSM.
The criteria remained the same; however, the requirement for a
psychological stressor to be present and feigning were removed.
Specific symptoms vary and can include weakness, paralysis,
trouble with swallowing, unusual speech, numbness, or unusual
sensory problems or a mixture of symptoms.
CD was studied by Sigmund Freud and Jean-Martin Charcot
dating back to the latter part of the nineteenth century. At the
29 Page 2 of 10
time, it was referred to as conversion hysteria and symptoms
were considered to be the conversion of emotional distress into
physical illness. Symptoms are not consciously produced to de-
ceive others for secondary gain, as in factitious disorder or ma-
lingering, but are rather physical manifestations of emotional
distress that are not under conscious awareness or control. The
precise prevalence of CD is not known. True conversion disorder
is thought to be rare and can range from 2 to 22/100,000 per year
[1, 2]. It may be more common in rural settings, lower socioeco-
nomic status, and/or among military personnel. The comparative
incidence among men and women is not known for certain [2].
The term conversion disorder will primarily be used
throughout this manuscript as the bulk of existing literature
reviewed used that term and corresponding criteria.
Conversion Disorder and Associated Somatic
Complaints
For most individuals with conversion disorder, the clinical pic-
ture and associated contextual factors are complex. Individuals
that typically present to tertiary health services experience ex-
tremely debilitating symptoms and their treatment can be diffi-
cult, protracted, and costly [3]. Furthermore, it is difficult to draw
conclusions from patients described as having CD, as researchers
tend to focus on specific symptoms (e.g., weakness, paralysis,
psychogenic nonepileptic seizures) included as part of the diag-
nosis [4]. In chronic pain disorders, the ability to distinguish
between physical or psychological factors also remains difficult,
as there are often no specific diagnostic tests and the reliability of
clinical judgment remains uncertain.
Conversion disorder has also been reported to present the
following surgical procedures. For example, a case study re-
ported the appearance of CD in a patient following implanta-
tion of a spinal cord stimulator with complex regional pain
syndrome [5]. Others have also found significant similarities
between the psychological profiles of patients with complex
regional pain syndrome (CRPS) and CD [6]. This study found
that patients in both groups evidenced high scores on the
Minnesota Multidimensional Personality Inventory hysteria
and depression scales. Furthermore, both groups showed high
rates of psychopathology comorbidity, particularly depression
and PTSD. The similarities between the two disorders found
by Shiri et al. [6] indicate the need to reexamine traditional
classifications (e.g., organic vs. psychiatric).
Although conversion disorder does not include the broader
array of nonspecific unexplained medical symptoms, such as
chronic fatigue or nausea, there does seem to be a correlation
with symptoms as well. For example, Kozlowska et al. [7]
found that symptoms of chronic pain and chronic fatigue were
reported to present in 56 and 34%, respectively, of children
diagnosed with conversion disorder. Additionally, chronic pain
syndromes have been reported in patients with psychogenic
Curr Pain Headache Rep (2017) 21:29
nonepileptic seizures [7, 8]. In fact, patients with psychogenic
nonepileptic seizures have been found to experience a more
severe form of migraine that is more frequent and longer in
duration than patients with epilepsy [9]. Furthermore, another
study concluded that patients with refractory seizures
complaining of either symptoms, chronic pain, or fibromyalgia
independently predicted the presence of psychogenic
nonepileptic seizures [10].
Studies have found that patients with psychogenic
nonepileptic seizures had significantly higher rates of chronic
pain disorders in addition to increased use of prescription pain
medications compared to patients with epilepsy [7, 11].
Similar to individuals with psychogenic nonepileptic seizures,
studies have found that individuals with functional weakness/
paralysis also experience more severe levels of chronic pain
than controls [12•]. Individuals with psychogenic nonepileptic
seizures have also been found to present with other somatic
comorbidities, including headaches [13], sleep disturbances
[10, 14], asthma [15, 16], obesity [17], and GERD [12•].
However, the conclusions derived from these studies are lim-
ited by only examining psychogenic nonepileptic seizures in
association with one condition [16, 18] or small sample sizes
[17]. Although not fully understood, the presence of illnesses
such as fibromyalgia, chronic pain, severe and chronic mi-
graines, asthma, and GERD can help clinicians who suspect
psychogenic nonepileptic seizures from epilepsy.
Neurological Assessment of Conversion Disorder
An adequate neurological assessment of CD requires detailed
history-taking and a thorough neurological examination as
well as laboratory and neuroimaging tests. Initial assessment
of suspected CD starts with a questionnaire regarding physical
symptoms. Patients should be asked about symptoms in all
organ systems. Pain, fatigue, sleep disturbance, and memory
and concentration problems may be prominent and should be
explicitly sought [19, 20•]. In addition, healthcare profes-
sionals must keep in mind that a history of depression, anxiety,
or panic attacks are common in these patients. Functional
conditions such as irritable bowel syndrome, fibromyalgia,
chronic pelvic pain, and multiple chemical sensitivity syn-
drome also have strong associations with CD [19, 20•].
A thorough neurological examination is necessary to assess
suspected CD. There are many tests that can be used to dis-
tinguish whether the symptoms are due to a functional origin
or an organic cause. For instance, in the lower extremity,
Hoover’s sign is the most commonly used test to assess func-
tional weakness. Hoover’s sign is present if the patient does
not push down with the normal leg when lifting the “weak”
leg [19, 21, 22]. Similarly, the “abductor sign” is another way
to assess functional weakness of the lower extremity when the
abduction of the “weak” hip becomes normal while the
Curr Pain Headache Rep (2017) 21:29
contralateral hip is abducting against resistance [20•, 21, 23].
Finally, patients with functional weakness may drag their en-
tire leg with external or internal rotation of the hip as opposed
to swinging or circumduction of the leg in patients with or-
ganic hemiparesis [19, 20•, 21]. Distractions can be used when
functional gait abnormality is suspected [6]. In those situa-
tions, distractions can significantly improve gait and balance
problems on physical examination.
In the upper extremity, there is the “finger abduction sign”
to look for while examining the patient. This involves asking
the patient to abduct the fingers of the normal hand against
resistance for 2 min; involuntary synkinesia would be seen in
the “weak” hand if positive [20•, 21], another easy test to try
and elicit the “drift without pronation sign.” A positive sign is
present when the “weak” arm drifts downward without pro-
nation with the patient’s eyes closed [20•]. Lombardi and col-
leagues recently proposed a new sign to detect functional arm
weakness—“the elbow flex-ex” test [24]. The patient is asked
to flex or extend the normal arm while the “weak” arm is
examined at the same time. In patients with functional weak-
ness, there is a detectable oppositional force in the “weak” arm
when the normal arm is tested [24]. In 44 patients tested, the
sign has correctly distinguished cause in all cases [24]. For
sensory symptoms, split vibratory sensation on forehead or
sternum is commonly used [20•]. Normally, vibratory sensa-
tion is felt equally when a tuning fork is placed on the midline
of forehead or sternum; however, patients with CD may com-
plain of decreased or complete loss of vibratory sensation on
one side of the forehead or sternum compared to the other
side.
The assessment of CD is not complete without laboratory
and neuroimaging tests as the positive sign of a functional test
does not rule out the underlying neurological or medical con-
ditions. Thus, routine laboratory tests (complete blood count,
chemistry, liver function test, thyroid function test, erythrocyte
sedimentation rate, C-reactive protein, etc.) and neuroimaging
tests including computerized tomography (CT) scan and mag-
netic resonance imaging (MRI) of the brain or the spine
should be performed at a patient’s first visit [20•].
Depending on the clinical presentation, CT angiogram or mag-
netic resonance angiogram (MRA) of the head and neck to
assess cerebral blood flow may also be indicated. Video elec-
troencephalogram (EEG) is very helpful to distinguish be-
tween activities that are suspicious for seizures and those that
are true seizures. The results of the laboratory tests and imag-
ing studies should be expected to be normal in CD. However,
one must keep in mind that the imaging and laboratory find-
ings of some of the chronic neurological diseases such as
amyotrophic lateral sclerosis (ALS) and autoimmune-related
neurological diseases are also normal; thus, a neurology
follow-up is advised to keep monitoring the symptoms that
were not suggestive of chronic neurological diseases at the
initial visit [23].
Page 3 of 10 29
Although there are no positive findings on standard brain
imaging for conversion disorder, functional MRI (fMRI), sin-
gle photon emission CT (SPECT), and positron emission to-
mography (PET) have demonstrated unique activation pat-
terns in multiple areas of the brain in patients with conversion
disorder [25••, 26]. For example, in patients with motor-
dominant symptoms, Voon et al. reported lower activity in
the left supplementary motor area (SMA) [27] and greater
activity in the right amygdala, left anterior insula, and bilateral
posterior cingulate [27], right temporoparietal junction (TPJ)
activity [28], and abnormal amygdala-SMA connectivity [29]
while completing different tasks. Yaźići and colleagues report-
ed reduced cerebral blood flow in the dominant temporal lobe
[30]. In addition, Aybek et al. showed increased involvement
of the periaqueductal gray area and left dorsolateral prefrontal
cortex (DLPFC) [31, 32]. Based on current studies, it appears
that dysfunctions in the cortical and subcortical motor path-
ways, parietal-temporal lobes, and limbic system may play an
important role in the clinical manifestations of CD [25••, 26].
Further studies are required to explore the brain activation
patterns associated with different symptoms of conversion
disorder.
Psychological Assessments of Conversion Disorder
Neuropsychological testing can help identify factors such as
psychological maladjustment, personality disorders, and sec-
ondary gain issues that perpetuate and maintain CD symp-
toms. The Minnesota Multiphasic Personality Inventory
(MMPI) is an objective personality assessment. The “conver-
sion V” response pattern has been known to be descriptive of
CD [33]. Elevations on the hypochondriasis and hysteria
scales compared to lowered scores on the depression scale is
suggestive of CD. However, due to the length of the MMPI
and skill required to interpret the results, it is not likely that it
will be practical for use in a typical outpatient medical clinic.
The Patient Health Questionnaire (PHQ-15) is a screening
tool that may have greater utility as part of assessing for and
diagnosing conversion disorders. The PHQ-15 is a 15-item
questionnaire that was developed from the “Primary Care
Evaluation of Mental Disorders” (PRIME-MD) [34] and the
“PRIME-MD Patient Health Questionnaire” (PRIME-MD
PHQ) [35, 36]. Respondents rate on a scale from 0 to 2 how
often symptoms are bothersome. Symptoms on the PHQ-15
include fatigue, dyspeptic complaints (nausea, gas, or indiges-
tion), stomach pain, back pain, pain in the joints or limbs,
trouble sleeping, headache, chest pain, bowel complaints
(constipation or diarrhea), menstrual pain or problems, dizzi-
ness, shortness of breath, palpitations, pain or problems during
sexual intercourse, and fainting. A cutoff of 10 was found to
have significant accuracy and discriminatory power (p ≤ .001,
CI = 0.71–0.82) [37] for somatoform disorder, but cannot
29 Page 4 of 10
differentiate between medically explained and medically un-
explained symptoms. This reinforces the idea that a compre-
hensive medical evaluation is an essential part of diagnostic
screening for CD.
Treatment of Conversion Disorder
The most successful treatment of CD is comprehensive and
multidisciplinary since presentation of symptoms is quite var-
ied. The strongest evidence for the treatment of CD is inpatient
multidisciplinary treatment. There was some support for cog-
nitive behavioral therapy (CBT) and mixed results for hypno-
sis. See Table 1 for a summary of results from highlighted
studies.
Inpatient Multidisciplinary Treatment
Several studies demonstrated the effectiveness of multidisci-
plinary inpatient treatment for severe motor CD [38, 41, 42••].
Programs typically consisted of psychological treatment
(CBT) and functional rehabilitation. McCormack and col-
leagues described their program as part of a retrospective
study. Participants had a chronic course of motor CD, with a
median duration of 4 years, high levels of disability, and un-
employment, and were dependent on others for assistance
with activities of daily living. The treatment was conducted
by a multidisciplinary team consisting of rehabilitation spe-
cialists and psychologists. Initially, a psychiatrist evaluated
patients to rule out possible neurological and medical causes.
Other medical specialists were consulted as necessary.
Patients found to have known medical illnesses were not in-
cluded in the study, as were patients who attributed motor
dysfunction to pain. A thorough history was taken examining
how symptoms began and factors that might predispose, pre-
cipitate, or maintain symptoms. The psychologist met with
patients using predominantly a cognitive behavioral approach,
psychoeducation, and relapse prevention strategies.
Neuropsychological testing was employed in some cases to
obtain a better understanding of patient presentation.
Physiotherapists and occupational therapists were seen twice
per week to work on physical rehabilitation goals, with graded
steps and positive reinforcement of progress. Techniques in-
cluded but were not exclusive to massage for dystonia, exer-
cises targeting posture, stability, balance, and strength.
Physiotherapists also helped patients reshape their illness per-
ceptions to a condition that is reversible, treatable, and nonor-
ganic in origin. This was followed by approaches to help
restore physical functioning. Finally, patients were taught re-
lapse prevention strategies to identify triggers for symptoms
and enact learned techniques promptly as needed to offset
reemergence of symptoms and disability. A functional
Curr Pain Headache Rep (2017) 21:29
analysis was conducted in the home environment to help pa-
tients reintegrate successfully into society. Generally, results
from this program were positive. Pre- to post-treatment scores
showed significant improvements in the performance of
ADLs (p < .001), mobility (p = .002), and Modified Rankin
Scale (MRS) score (p < .001). The MRS is a measure of
disability that is typically used in stroke medicine.
Cognitive Behavioral Therapy
While there is ample evidence to support the use of cognitive
behavioral therapy for chronic pain [43], there was only one
randomized controlled clinical trial for the support of CBT for
psychogenic seizure, which some consider a form of conver-
sion disorder. In a pilot study conducted by Goldstein and
colleagues, they found that 12 sessions of CBT resulted in
reductions of dissociative seizures and improved psychosocial
functioning [46]. They followed up this study with a prospec-
tive randomized controlled study comparing CBT with stan-
dard medical care (SMC) [40]. The CBT group also received
SMC. Sixty-six patients with psychogenic, nonepileptic sei-
zures participated in this study. It was found that seizure re-
duction following CBT was superior to that of the SMC group,
with medium to large effect sizes. The CBT group was more
likely to have experienced a period of 3 months without sei-
zures and significantly fewer seizures at the end of treatment,
yet there were no significant changes in mood and employ-
ment status. For both of these studies, CBT content involved
the following:
1) Sessions 1–2: Self-monitoring and education for the pa-
tient and caregivers with efforts to reduce reinforcing mal-
adaptive responding.
2) Sessions 3–5: Distraction and refocusing techniques; re-
laxation and controlled breathing; cognitive restructuring
strategies and working with maladaptive thinking.
3) Session 6–9: Review of treatment to date and identifying
issues to be addressed for the next three sessions.
4) Session 10–11: Relapse prevention and discharge plans.
Caregivers were encouraged to attend the first session and
the sixth session to assist in treatment planning and coping
with setbacks.
LaFrance and colleagues conducted a prospective trial with
21 patients diagnosed with psychogenic, nonepileptic seizures
[39]. The sessions lasted 1 h and consisted of the following
topics:
Introduction: Understanding seizures.
Session1: Making the decision to begin the process of taking
control and getting support.
Session2: Getting support.
Curr Pain Headache Rep (2017) 21:29 Page 5 of 10 29

Table 1 Summary of treatment

studies for the treatment of Hypnosis or hypnotherapy
conversion disorder or functional Authors Moene, Spinhoven, Hoogduin, Van Dyck [38]
neurological disorders Year 2003
Methods Randomized controlled clinical trial. Subjects were blinded to group.
Participants N = 44 diagnosed with motor CD or somatization disorder with motor conversion
symptoms
Interventions Hypnotherapy: ten 1-h sessions with a psychotherapist trained in hypnosis with
psychiatric populations. Participants were encouraged to practice 30 min on their
own each day outside of sessions.
Outcomes Increased functioning as measured by the VRMC that were consistent at 6-month
follow-up
Cognitive behavioral therapy (CBT)
Authors Goldstein, Chalder, Chigwedere, Khondoker, Moriarty, Toone, Mellers [39]
Year 2010
Methods Randomized controlled trial comparing CBT with standard medical treatment
Participants N = 66 diagnosed with psychogenic nonepileptic seizure disorder
Interventions 12 1-hour-long weekly outpatient psychotherapy sessions
Outcomes CBT group was statistically significantly improved at the end of the treatment in
terms of seizure frequency; other measures such as social functioning and health
service use showed improvement in both groups. There were no changes in mood.
Authors Goldstein Deale Mitchell-O’Malley, Toone, Mellers [40]
Year 2004
Methods Prospective single group pre- and post-treatment, with 6-month follow-up.
Participants N = 20; diagnosed with dissociative seizures
Interventions 12 1-h-long treatment sessions, with an exception of the first session that was longer,
up to 2 hours. Sessions were held once every 1 to 2 weeks.
Outcomes Improvements in seizure frequency and psychosocial functioning, at least a 50%
reduction in dissociative seizure frequency, four patients were completely seizure
free at 6-month follow-up
Authors LaFrance, Miller, Ryan, Blum, Solomon, Kelley, Keitner [41]
Year 2009
Methods Prospective single group pre- and post-treatment
Participants N = 21, with 17 completers; diagnosed with psychogenic nonepileptic seizure
disorder
Interventions 1-h treatment sessions conducted on an outpatient basis: introduction and 12
treatment sessions
Outcomes From baseline to final session: decreased frequency of seizures; improvements on
depression, anxiety, somatic symptoms, quality of life, and psychosocial
functioning.
Inpatient multidisciplinary treatment
Authors Kuyk, Siffels, Bakvis, Swinkels [42••]
Year 2008
Methods Single group prospective inpatient treatment for psychogenic, nonepileptic seizures
Participants N = 22
Interventions Comprehensive multidisciplinary treatment with a goal of reducing psychogenic
seizures. Information and education about nonepileptic seizures. CBT approach.
Average length of treatment was 4.8 months.
Outcomes 81% of participants had over 50% reduction of seizures and half were seizure free.
Reduction of seizure medication from 63.6% at admission to 9% at follow-up
Authors Moene, Spinhoven, Hoogduin, vanDyck [43]
Year 2002
Methods Randomized controlled clinical trial. Experimental group = hypnosis; control
group = patients in the inpatient program who were not treated with hypnosis.
Participants N = 45 inpatients who met clinical criteria for conversion disorder of the motor type
or somatization disorder with motor conversion symptoms.
29 Page 6 of 10 Curr Pain Headache Rep (2017) 21:29

Table 1 (continued)
Interventions Group psychotherapy and individual physiotherapy program. Physical rehabilitation
lasted 1h, three times per week during the first 6weeks and 2h per week during the
last 6weeks. Participants practiced exercises five times per week on their own.
Hypnotherapy involved eight weekly sessions of 1h and one introduction session.
Participants also learned self-hypnosis. In the control condition, participants also
participated in eight weekly sessions of 1h of psychotherapy, but the focus was on
nonspecific common therapy factors. Therapy involved exploring stressors from the
past and present that could perpetuate the disorder.
Outcomes All patients regardless of condition experienced significant symptom reduction;
65.1% were substantially improved on the VRMC post-treatment and at 6-month
post-treatment follow-up. The hypnosis group did not do significantly better than the
control group.
Authors McCormack et al. [44]
Year 2014
Methods Retrospective study; archival data was extracted looking at pre- and post-treatment
data
Participants n=33; 78% female; diagnosed with severe motor CD; mean duration of illness was 48
months.
Interventions Inpatient treatment in a specialist neuropsychiatry unit with a multidisciplinary
approach that includes a neuropsychiatrist, psychologist, physiotherapist, and
occupational therapist.
Outcomes Significant improvements in Modified Rankin Scale scores, mobility, and ADLs
Paradoxical intention treatment
Authors Ataoglu, Ozcetin, Icmeli, Ozbulut [45]
Year 2003
Methods Prospective study comparing paradoxical intention therapy (PI) and diazepam; 15 pts
received paradoxical therapy and 15 pts received diazepam; allocation into groups
was randomized.
Participants n=30; diagnosed with CD
Interventions PI therapy provided inpatient in a psychiatric unit, two sessions per day for 3weeks.
Diazepam (5–15mg/day) was provided in an outpatient setting with a psychiatrist.
Four total appointments.
Outcomes 93.3% responded well to PI therapy. 60% responded well to diazepam. PI therapy pts
had greater improvements in Hamilton Rating Scale scores for anxiety (z=2.43,
p<.015) and conversion symptoms (t=2.27, p=.034) compared to pts treated with
diazepam.

Session3: Deciding about your medication therapy. Hypnosis/Hypnotherapy

Session4: Learning to observe triggers.
Session5: Channeling negative motions into productive
outlets.
Session6: Relaxation training.
Session7: Identifying preseizure aura.
Session8: Dealing with external life stresses.
Session9: Dealing with internal issues and conflicts.
Session10: Enhancing personal wellness: learning to reduce
tensions.
Session11: Other seizure symptoms.
Session12: Taking control: an ongoing process.
Participants demonstrated improvements in reducing sei-
zure frequency and significantly improved quality of life, fam-
ily functioning, and psychosocial functioning by the end of
treatment.
Overall, the results for CBT in the treatment of psychogen-
ic seizure have been positive, but more systematic research
needs to be done to consider CBT as a clinically meaningful
intervention for CD.
Hypnosis has been used for many years to treat various con-
ditions such as smoking cessation, overeating, and psycholog-
ical trauma. Assistance through hypnosis can help alter
thoughts, feelings, expectations, attitudes, perception, and be-
havior for a desired effect. Medical or procedure hypnosis is a
form of hypnosis that entails forming a rapid rapport and using
brief hypnotic techniques to help make medical procedures
more comfortable, safer, and faster [47]. The process involves
a hypnotic induction that helps patients achieve a state of
attentive and receptive concentration. An introduction of hyp-
notic suggestion follows. For example, imagine one’s hand is
in a bucket of ice cubes. At the end of the procedure, the
patient is guided out of the hypnotic state. With training and
practice, patients can also do this on their own through self-
hypnosis. There is a great deal of evidence to support the use
of hypnotherapy for chronic, acute, and procedural pain
[47–49]. See Patterson and Jensen’s review of hypnosis and
clinical pain for more detailed information about studies
supporting the use of hypnosis for pain [50]. Evidence to
Curr Pain Headache Rep (2017) 21:29
support the use of hypnotherapy for CD is limited compared
to pain and mostly anecdotal. Two experimental studies
showed mixed support for hypnosis or hypnotherapy. Moene
and colleagues conducted a randomized controlled clinical
trial of a hypnosis-based treatment for individuals with motor
CD [51]. Forty-four patients with either motor CD or somati-
zation disorder, with motor type symptoms, were randomly
assigned to a hypnosis or wait list condition. For both the
control and experimental groups, there was a preassessment.
The experimental group engaged in ten treatment sessions
lasting 1 h. This group was also trained in self-hypnosis and
asked to practice 30 min each day. An audio cassette was
provided for guidance outside sessions. No therapy took place
for the control group. Hypnotherapy was composed of two
treatment strategies: direct symptom alleviation and emotional
expression/insight. Indirect symptom alleviation, specific con-
version symptoms were targeted with hypnotic suggestions.
For instance, an individual with limb paralysis would be given
suggestions regarding the perception of tingling or tiny mus-
cle spasms in the paralyzed limb. In the expression and insight
approach, age regression was employed for individuals who
had experienced an event that was thought to be related to the
onset of symptoms. The hypnotic suggestion would involve
expressing the emotions associated with the event. Hypnosis
was found to be effective for reducing symptoms and impair-
ments in physical daily life and social activities according to
the Video Rating Scale for Motor Conversion Symptoms
(VRMC). These improvements were maintained at 6-month
follow-up. Although psychopathology as measured by the
Symptom Checklist (SCL-90) did not improve significantly,
there was a trend towards improvement.
Moene and colleagues also conducted an inpatient RCT for
inpatient comprehensive treatment of severe motor CD symp-
toms examining the effects of hypnosis for symptom reduction
[38]. All patients in this program made significant gains in
functioning and reduction of motor conversion symptoms. It
was concluded that the use of hypnosis had no additional effect
on treatment outcome. The authors speculated that a small
sample size (n = 45) resulted in insufficient power to detect a
significant difference between the hypnosis and control
groups. Additionally, there may have been contextual influ-
ences on the results. All participants were in a supportive en-
vironment where patients felt accepted and understood, thus,
feeling validated rather than rejected or punished. This in com-
bination with the comprehensive approach of the program may
have been sufficient for symptom amelioration so that the con-
tribution of hypnotherapy was not detectable in this study.
Paradoxical Intention Treatment
Paradoxical intention (PI) therapy involves suggesting that
patients intentionally engage in an unwanted behavior.
Page 7 of 10 29
Ataoglu and colleagues compared PI therapy with an anxi-
olytic medication, diazepam [44]. Dosages ranged from 5 to
15 mg per day. Patients were randomly distributed into the
two groups. Individuals in the PI group were hospitalized
for 3 weeks while engaged in this treatment. They were
informed about the nature of the inpatient treatment, what
was expected of them, and approximately how long the
treatment would last. The relationship between anxiety
and conversion symptoms was also explained to them.
Study participants engaged in this therapy twice per day.
They were asked to imagine an anxiety-provoking situation
to elicit conversion symptoms. Therapists helped partici-
pants remember and reexperience specific traumatic events.
Participants in the diazepam group saw a psychiatrist on an
outpatient basis and were followed up at days 10, 20, 30,
and 45 of the 6-week treatment period.
Other Approaches or Treatments
Although there are no controlled studies using transmagnetic
stimulation (TMS), preliminary results show some promise
[45]. There are several hypothesized explanations for how
TMS might exert therapeutic benefits from neuromodulatory
effects to changing beliefs or expectations about symptoms to
produce a therapeutic effect. There is a great deal of variability
in the protocols used in studies so far. Therefore, it is difficult
to establish a standardized methodology whereby to use TMS.
A case study was used as an illustration of how educating
or sharing results from neurological tests (for example,
Hoover’s sign) and how medical providers come to the con-
clusion of conversion or psychogenic illness can be a helpful
tool [52]. This approach suggests that acceptance of and un-
derstanding one’s diagnosis of CD can lead to positive thera-
peutic results.
There was one study examining group psychotherapy
with a psychodynamic focus [53]. Twelve patients diag-
nosed with psychogenic, nonepileptic seizures participated
in 32 weekly group psychotherapy sessions. The group ini-
tially started with a psychoeducational focus and relaxation,
and self-hypnosis was used with the beginning of any sei-
zure activity. The goal of therapy was to facilitate awareness
of external manifestations of internal processes with child-
hood experiences critical to the development of maladaptive
behavioral patterns. Increased insight of defense mecha-
nisms that perpetuate dissociation and trigger seizure activ-
ity also allowed for possible change. Six out of the seven
patients who completed the study experienced a decrease in
frequency of seizures and improvements in quality of life.
Several months after the intervention most of the partici-
pants found that their seizures were less frequent and less
incapacitating.
29 Page 8 of 10
Conclusions
Conversion disorder, now known as Functional Neurological
Symptom Disorder, is a complex condition with symptoms
that overlap between medical and psychiatric illness and can
be perpetuated by factors in the patient’s social environment.
Early diagnosis and treatment may prevent the need for un-
necessary tests and treatments. Overlooking an underlying
medical condition must be avoided; thus, comprehensive
and thorough medical assessment is required prior to settling
on this diagnosis. Consultations with specialists in neurology
and psychiatry are often beneficial to help rule out primary
medical conditions. It is important to remember that CD
symptoms may be comorbid with chronic pain conditions
such as irritable bowel disease, CRPS, migraine headaches,
or fibromyalgia [6–8, 19, 20•]. Many individuals with conver-
sion symptoms present first to primary care settings, and early
recognition of possible CD would help to facilitate referral to
an appropriate specialist. Psychological assessments and neu-
ropsychological testing can be helpful tools, in concert with
patient interview and medical evaluation (e.g., physical exam,
neuroimaging, and laboratory tests). Early identification of
CD helps lead to earlier treatment ideally so that symptoms
will not become more severe.
According to our review of the literature, there are no well-
established treatments for CD. However, there was strong ev-
idence for inpatient multidisciplinary treatment and some sup-
port for CBT and hypnotherapy as separate interventions. The
combination of CBT, hypnotherapy, and physical rehabilita-
tion showed the most promise for long-standing chronic con-
version symptoms. In the presence of pain and conversion
symptoms, there were no studies available.
There is overlap of the treatment options for CD and certain
chronic, severe, and intractable pain conditions. For instance,
the clinical guidelines for the treatment of CRPS recommend
interdisciplinary care with a focus on functional restoration
and psychotherapy [54]. This is similar to the approach used
for inpatient treatment of CD, albeit with a different focus.
Inpatient multidisciplinary or interdisciplinary treatment may
be necessary in the most severe cases.
Patient refusal to accept the diagnosis can prove to be a
significant barrier in pursuit of appropriate treatment.
Education, a supportive therapeutic alliance, and collaborative
treatment planning may help patients overcome any stigma or
resistance to accepting the diagnosis of CD and facilitate ap-
propriate treatment. Some suggestions for healthcare profes-
sionals to overcome resistance include the following: sched-
uling appointments on a regular basis rather than as needed,
performing brief physical examinations at each visit regard-
less of need and avoiding any unnecessary diagnostic proce-
dures, invasive treatments, or hospitalizations (i.e., overly
medicalizing the condition). Probably the most important is
to avoid explaining symptoms as “all in your head,” which
Curr Pain Headache Rep (2017) 21:29
invalidates the individual’s suffering by suggesting a nonor-
ganic cause for symptoms and the possibility that there is no
cure for the individual’s condition [55].
In summary, treatment for CD and chronic pain may be
similar and some components can be used for either condition.
Accurate diagnosis is crucial in selecting the appropriate treat-
ments and healthcare provider-patient alliance is extremely
important for facilitating acceptance of the recommended
treatments. More severe CD symptoms may require inpatient
admission.
Acknowledgements The authors would like to thank Dr. Christopher
Robin Page for editing this paper and providing valuable feedback.
Compliance with Ethical Standards
Conflict of Interest Patricia Tsui, Andrew Deptula, and Derek Y. Yuan
declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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