Psychosomatics 45:492-499, December 2004
© 2004 The Academy of Psychosomatic Medicine
Motor Conversion Symptoms and Pseudoseizures: A Comparison of Clinical Characteristics
Jon Stone,
Michael Sharpe, and
Michael Binzer
Received July 2, 2003; revision received Feb. 25, 2004; accepted March 10, 2004. From the Division of Clinical Neurosciences, School of Molecular and Clinical Medicine, Western General Hospital, University of Edinburgh; the Division of Psychiatry, School of Molecular and Clinical Medicine, Royal Edinburgh Hospital, University of Edinburgh, Edinburgh; and the Department of Neurology, University of Southern Denmark, Esbjerg Hospital, Esbjerg, Denmark. Address reprint requests to Dr. Stone, Division of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU U.K.; jstone{at}skull.dcn.ed.ac.uk (email).
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ABSTRACT
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The authors prospectively studied consecutive neurological inpatients with either motor conversion symptoms or pseudoseizures of recent onset. Patients were administered a structured psychiatric diagnostic interview, a measure of perceived parental care, and a life events inventory. They found that patients with pseudoseizures (N=20, mean age=27 years): 1) were younger than patients with motor conversion symptoms (N=30, mean age=39 years), 2) were more likely to have a borderline personality disorder), 3) were more likely to have a lower perception of parental care and to report incest, and 4) reported more life events in the 12 months before symptom onset. These differences in their characteristics and associated factors raised the question of whether it is helpful to group patients with pseudoseizures and motor conversion symptoms in a single diagnostic category of conversion disorder. An alternative view, that gives primacy to the symptoms rather than a disorder, may enable more precise research questions to be posed.
Key Words: borderline personality • epilepsy • child abuse • somatoform disorders
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INTRODUCTION
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Conversion disorder is defined in DSM-IV as the occurrence of symptoms that mimic neurological disease (paralysis, seizures, and sensory disturbance but not pain, fatigue, or sexual dysfunction) that are not intentionally produced and do not occur exclusively in the course of somatization disorder. The definition also states that 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.1 Conversion disorder remains a contentious diagnosis. It may be regarded as a refuge, both for patients with pseudoneurological symptoms who do not fulfil criteria for somatization disorder and for psychodynamic concepts in the DSM-IV. Unlike somatization disorder, there have been few studies of its diagnostic stability and reliability and none to our knowledge formally examining the rationale for the selection and grouping of paralysis, seizures, and sensory disturbance (excluding pain) in their own single category.
Studies of conversion disorder have either concentrated on individual symptoms such as dysphonia or pseudoseizures or have grouped various pseudoneurological symptoms as a single entity. As far as we are aware, no previous study has compared clinical characteristics and associations in patients with different types of conversion symptoms taken from the same patient population.
This study is of patients recruited from neurological centers who had only recently developed their symptoms for the first time. One group had weakness (paresis or paralysis of a limb) that was unexplained by neurological disease (that in this article we will refer to as "motor conversion symptoms") and the other had seizures that were unexplained by neurological disease (that we will refer to as "pseudoseizures"). The groups were compared on demographic variables, psychiatric diagnoses, and symptoms and personality disorder. We also compared the strength of association with the proposed etiological factors of adverse childhood experiences and recent life events.
The hypotheses tested were generated before data analysis from clinical experience and previous studies. These hypotheses were that patients with pseudoseizures, when compared to those with motor conversion symptoms, would 1) be more likely to be female,2–10 2) be younger in age,4,7,10–16 3) be more likely to have a borderline personality disorder,17–19 4) be more likely to report sexual abuse or problems in childhood,20,21 and 5) report more recent life events.22,23 We measured psychiatric disorder (DSM-IV, axis I) but did not expect to find a difference between groups in its prevalence.24 We also examined the extent to which motor conversion symptoms and pseudoseizures occurred simultaneously in the same patient and the frequency of pain in both groups.
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METHOD
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Setting
The patients with motor conversion symptoms and those with pseudoseizures in this study have been previously described.25,26 All patients were recruited over the same time period from two hospitals: the Department of Neurology at Umeå University Hospital in northern Sweden and the neurological section of the Department of Internal Medicine at the county hospital of Kalmar in the south of Sweden. Both hospitals have primary catchment areas of approximately 130,000 inhabitants, but Umeå University Hospital also offers neurological services to a secondary catchment area with a population of around 800,000 people.
Recruitment and Selection
In Umeå, the period of recruitment lasted 24 months for patients with motor symptoms and 48 months for patients with seizure disorders, whereas in Kalmar, the inclusion period lasted 22 months for both patient groups. The selection procedure at the two sites was identical. Non-Swedish speakers were excluded.
Consecutive patients with motor symptoms or seizures who were admitted to the in-patient wards of the two hospitals and fulfilled DSM-IV criteria for conversion disorder were considered for inclusion in the study. The diagnoses in all cases were confirmed by at least two different neurologists. Patients with concomitant somatic diseases other than neurological illnesses and patients with concomitant psychiatric syndromes other than somatization disorder were included. Patients with both conversion disorder and known neurological disease were excluded, as were patients with probable conversion disorder in which a neurological cause was judged unlikely but difficult to rule out completely.
Only patients with paresis or paralysis of less than 3 months' duration were included in the group with motor conversion symptoms. Patients with a psychogenic movement disorder or psychogenic gait disturbance were excluded. Patients with disease that could have caused their motor symptoms were excluded. Patients were assessed for the presence of disease by means of clinical assessment, including relevant radiological, neurophysiological, and biochemical investigations. The level of investigation depended on the certainty of the clinical presentation. However, all patients underwent neuroradiological investigations with computerized tomography or magnetic resonance imaging.
Only patients seen less than 12 months after the first pseudoseizure were eligible for inclusion in this group. Patients with pseudoseizures who also had epilepsy were excluded. Patients were assessed for the presence of epilepsy with long-term in-patient closed-circuit video and EEG monitoring, and those with a normal EEG during a clinical seizure were included.
Measures
Background information concerning previous medical and psychiatric disorders was collected by interview and by a review of hospital records. Information about previous medical and psychiatric disease among relatives was also obtained by a standardized interview. The research assessment was conducted during the patients' hospitalization by an interviewer who was blind to the specific hypotheses and consisted of the following.
Psychiatric diagnoses were determined with the Structured Clinical Interview (SCID) for Diagnostic and Statistical Manual for Mental Disorders (DSM-IV): the SCID-I for clinical syndromes and the SCID-II for personality disorders. These are structured clinical interviews linked to the DSM-IV diagnostic system.27 They provide suggested wording for questions and criteria for judging the patient's response but also allow for clinical judgment in interpreting whether the patient's responses meet the criteria. They have been shown to generate reliable diagnosis when used by trained clinicians.28 The SCID-II interview covers the 11 personality disorder (axis II) diagnoses. The instrument has been validated against "longitudinal expert evaluation using all data"29 and has high test-retest and interrater reliability.30
Patients also scored their level of psychological, social, and occupational functioning over the previous year according to axis V of DSM-IV by means of a validated self-report version of the Global Assessment of Functioning (GAF) scale.31
Perceived parental rearing practices were assessed by means of the Egna Minnen Beträffande Uppfostran (My Memories of Upbringing) self-rating inventory,32 which is based on 12 qualities of child-rearing experiences: abusive, depriving, punitive, shaming, rejecting, overprotective, overinvolved, tolerant, affectionate, performance orientated, guilt engendering, and stimulating. A total of 81 questions can be answered in four ways for the father and for the mother separately: 1) it never occurred, 2) it could occur but it was exceptional, 3) it occurred quite frequently, 4) it was always so. A factor analysis has extracted three principal components: emotional warmth, rejection, and overprotection. The Egna Minnen Beträffande Uppfostran has been demonstrated to be highly convergent33 in content to the widely used Parental Bonding Instrument,34 which has only two dimensions (care and control/overprotection).
The occurrence of life events 12 to 4 months before and within 3 months of the onset of the symptom were assessed by using a 56-item life events inventory elicited by semistructured interview.6,35 Life events were sorted into events concerning 1) work, 2) family life, 3) health problems among friends and relatives, and 4) events related to the patient's own health. It was also recorded whether the life event was expected or not, positive or negative, and easy or difficult to adjust to.
The study was approved by the research ethical committee of Umeå University in Sweden. All patients received oral and written information about the project, and written consent was obtained in all cases.
Analysis
The hypotheses were tested by comparing the groups. Unpaired t tests or Mann-Whitney tests were used, depending on whether the data were normally distributed. Fisher's exact test was used to compare proportions.
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RESULTS
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Twenty patients with pseudoseizures and 30 patients with motor conversion symptoms were recruited. Two patients in the pseudoseizure group and none in the motor conversion group refused to participate in the study. Neuroimaging was normal in all participating patients.
Basic demographic data are shown in Table 1. The patients with pseudoseizures were substantially and significantly younger (mean age=27 years) than the patients with motor conversion symptoms (mean=39 years) (p<0.05, unpaired t test) and were more likely to be unmarried and not to have children. There was no difference in the proportion of women. The patients with pseudoseizures were more likely to have completed a high school education (p<0.01, Fisher's exact test), although both had a similar social class profile.
The data from the diagnostic psychiatric interview (Table 2) indicate little difference between the patients with pseudoseizures and those with motor conversion symptoms. Both had high levels of emotional disorder and personality disorder. Although there was no major difference in the proportion with all personality disorder types, there was a substantially and significantly higher proportion of patients with borderline personality disorder in the group with pseudoseizures (35% c.f. 7%) (p<0.05, Fisher's exact test).
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TABLE 2. Psychiatric and Medical Characteristics of Patients With Pseudoseizures and Patients With Motor Conversion Symptoms
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Table 3 summarizes factors relating to childhood. There was a higher incidence of parental divorce in the pseudoseizure group than in the motor conversion group. Six of the 20 pseudoseizure patients reported incest compared to only one patient in the motor conversion group. The perceived parental rearing inventory scores indicated significantly lower perceived emotional warmth from both parents and a higher perception of rejection from the father in the pseudoseizure group.
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TABLE 3. Childhood Experiences and Recent Life Events of Patients With Pseudoseizures and Patients With Motor Conversion Symptoms
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The results of the life events interviews are also shown in Table 3. The overall number of life events in the 12 months before assessment was significantly higher in the pseudoseizure group than in the motor conversion group (p<0.0001, unpaired t test) but not if only the 3 months before onset was considered. Patients in both groups reported life events that were perceived as negative, unexpected, or difficult to adjust to. Patients with motor conversion symptoms experienced their life events significantly more negatively than those with pseudoseizures (p<0.01, unpaired t test). A high proportion of life events reported by both groups related to personal health issues or health problems in family or friends. In the motor symptom group, 71% of the life events experienced were of this nature compared to 53% in the pseudoseizure group (although the absolute number of life events compared to the pseudoseizure group was similar). The difference in the number of life events over 12 months was primarily made up of an excess of events relating to family life in the pseudoseizure group (p<0.005, unpaired t test).
One of the patients with pseudoseizures had a history of a transient motor conversion symptom in the past. Two of the patients with motor conversion symptoms had a history of pseudoseizures. Pain was a common symptom in both the pseudoseizure (30%) and motor conversion (50%) groups.
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DISCUSSION
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The data presented provide evidence of differences in the characteristics and etiological associations between the patients with pseudoseizures and the patients with motor conversion symptoms. Because these findings were from patients with similar symptom durations, the confounding effects of differential chronicity as a cause of these findings was reduced.
Patients with pseudoseizures have symptoms at a younger age and are more likely to report adverse childhood experiences. There was a 12-year difference between the mean ages of the two groups in this study, which confirmed our hypothesis. This difference probably explains the significantly higher number of previous hospital admissions with somatic symptoms in patients with motor conversion symptoms as well as the finding that patients with pseudoseizures were more likely to be unmarried and not have children.
Adverse childhood experience was particularly common in the pseudoseizure patients, in keeping with our hypotheses. Similarly, incest and borderline personality disorder, which themselves correlate strongly with measures of childhood abuse, were more common in this group. These data raise the possibility that the symptom of pseudoseizures is more strongly associated with adverse early life events and the subsequent effect of those on personality than on motor conversion symptoms. In contrast, while these factors may be equally important for some patients with motor conversion symptoms, perhaps motor symptoms tend to arise on a broader range of psychosocial backgrounds in response to a greater variety of stimuli, such as fatigue, previous somatic disease, and pain.
Patients with pseudoseizures report more life events. We found a higher rate of life events, particularly related to family life, in the pseudoseizure group in the 12 months preceding the assessment. This supports our hypothesis and lends further support to the hypothesis that pseudoseizures may be more driven by life events than motor symptoms. It is interesting to note that there was not a particular excess of life events in the 3 months before onset (compared to the whole 12 months) in either conversion group. This suggests that if life events are important in the genesis of symptoms, they do not necessarily have to be closely temporally related to the onset of symptoms. This is contrary to definitions of conversion disorder that require such a temporal correlation. Even the most recent DSM-IV classification of conversion disorder still requires that the "initiation or exacerbation of the symptoms or deficit is preceded by conflicts or other stressors."
Limitations
The principal limitation of this study is the small numbers of patients involved. Given the number of tests performed, it is possible that some of the statistically significant differences between the groups occurred by chance. Although the interviewer was not blind to diagnosis—a problem with nearly all studies of this type—the data were collected blind to the specific hypotheses being tested.
The findings are only generalizable to patients who do not meet any of the exclusion criteria of this study, most notably DSM-IV somatization disorder. In practice, a number of patients presenting with conversion symptoms also meet criteria for this diagnosis. If they had been included, measures of distant predisposing factors, such as childhood and personality disorder may have been even higher, but the number of precipitating life events may have been lower since, in our experience, patients with this diagnosis often develop recurrent new symptoms without significant new life events producing them. It should also be emphasized that only patients with a DSM-IV diagnosis of somatization disorder (and not just a history of somatoform symptoms) were excluded. An additional limitation on the generalizability of these findings is that all the patients in this study were inpatients. Outpatients or patients with functional neurological symptoms in the community probably have less disabling symptoms and less psychiatric comorbidity.
However, there were also strengths to the sampling procedure used in this study. Consecutive patients seen as neurological referrals in a secondary referral center were recruited. This made them closer to a community sample than a sample from a psychiatric service or tertiary referral centers, such as specialist epilepsy services, which have formed the basis for most previous studies.
Finally, two of the principal areas being studied, life events and childhood experiences, are subject to problems of reporting bias, both in terms of accurate recollection and the influence of the subject's personality and emotional state.
Studies Comparing Pseudoseizures and Motor Conversion Symptoms
Only in the 1957 study by Ljungberg9 can one find a degree of systematic comparison between a group of patients with motor conversion symptoms and a group of patients with pseudoseizures across a range of measures. Ljungberg found that in the group with paralysis, 53% were male compared to only 26% who were male in the pseudoseizure group. He also found no difference in the age of onset or prognosis between these two groups. He also found that the risk of hysteria in the mothers and sisters of patients with pseudoseizures (13%) was higher than that of the other groups (3.5%). Maxion et al.36 demonstrated in their series of patients with conversion disorder that patients with pseudoseizures had a slightly lower age of presentation than patients with motor symptoms, although mean ages were not given. Two additional studies reported data showing similar symptomatic outcomes in pseudoseizures compared to motor symptoms but without other comparative data.37,38
A review of the published controlled studies on the childhood, life events, and psychiatric morbidity of patients with pseudoseizures and motor conversion symptoms is outside the scope of this article but can be found elsewhere.26,39 Furthermore, these studies cannot be easily compared since they are drawn from heterogenous populations and have generally used different measures. Simple variables, however, are comparable. In a brief analysis, we examined all of the studies of motor conversion symptoms (paralysis) and pseudoseizures that we are aware of that were published since 1965 in which the sex or age of onset (or age of presentation combined with the duration of symptoms) are reported in consecutive patients. We excluded studies in which patients with paralysis were mixed with those with pseudoseizures or movement or gait disorder.13–16,40–42
There were six studies of 167 patients with paralysis reporting an average proportion of 48% women.5–10,25 In one further study, 57% of 1,316 patients seen at a Chinese hysterical paralysis treatment center were women.43 A review of 46 studies of pseudoseizures that we were aware of, with a total of 2,103 patients, indicated that 74% of these were women, which was significantly higher than the paralysis group (p<0.0001) (references available from the first author). There were insufficient studies to analyze age at onset in studies of paralysis only.7,10 When we included studies reporting age at onset in gait disorder and mixed studies with high proportions of patients with paralysis, there were six studies reporting a combined average age at onset of 34 years.7,10,13–16 In 22 studies of pseudoseizures, however, only two articles reported an average age of onset greater than 30 years (references available from the first author). This preliminary literature analysis supports two of the hypotheses of our study: that pseudoseizures tend to appear at a younger age and are more likely to occur in women than motor conversion symptoms.
In this study, there was a high frequency of pain in both groups but a much smaller overlap between pseudoseizures and motor conversion symptoms. This has been previously reported.7,13–15,44,45 Studies that have found a large overlap in background factors between somatoform pain disorder and conversion disorder46 echo the increasing realization that rather than forming separate and distinct categories, functional somatic symptoms consistently overlap.47–49
Implications for DSM Classification of Conversion Disorder
At present, the only reason pseudoseizures and motor symptoms seem to be grouped together in DSM-IV conversion disorder appears to be because they both imitate neurological disease. In ICD-10, the argument that they both are associated with a dissociative mechanism is arguably more logical. However, apart from the findings of Roelofs et al.,50 most of the evidence that dissociation is in fact the mechanism comes from studies that have compared conversion disorder with organic disease controls. One must therefore ask whether dissociation, usually measured by dissociative scales, is specific to conversion symptoms or simply common to many different somatic and/or psychological symptoms.2,51,52
If it can be demonstrated 1) that patients with pseudoseizures have a consistently different psychosocial profile than patients with motor conversion symptoms and 2) that pseudoseizures cluster much more with other symptoms, such as pain, than they do with motor conversion symptoms, this raises questions about the homogeneity of the current diagnostic category of conversion disorder.
What about the natural history of patients with these symptoms as a differentiating feature? This cross-sectional study of recent-onset symptoms cannot tell us whether the younger patients with pseudoseizures may at a later date be especially vulnerable to motor conversion symptoms or vice versa. Despite a handful of studies demonstrating symptom persistence in a majority of patients and some crossover with somatization disorder,53,54 longitudinal studies of large prospective cohorts are needed to establish the predictive validity of the diagnosis, particularly with respect to the rationale for grouping and separating pseudoneurological symptoms from other somatoform symptoms, such as pain.48
One may further question whether conversion disorder really is a disorder or merely a collection of patients with symptoms that imitate neurological disease. The two other criteria in DSM-IV that separate conversion symptoms from conversion syndrome are 1) that psychological factors are judged to be relevant and 2) that the symptom is not intentional or feigned. In practice, both of these criteria require judgments that are difficult or impossible to be certain of. We join other authors who have come to the conclusion that until evidence appears to the contrary, the phenomena described in this article are better described as a different type of conversion symptom rather than combined as conversion disorder.55–57
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CONCLUSIONS
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This study suggests that pseudoseizures appear at a younger age and are more likely to be associated with external factors such as life events and childhood adverse experiences, whereas motor conversion symptoms tend to occur later in life and are less dependent on life events. The symptoms of paralysis and seizure-like episodes unexplained by disease are probably best seen as symptoms rather than as manifestation of a disorder. They share factors, such as personality disorder and childhood experience, which are more common in cases than in patients with disease or the general population. However, these factors are similar to those associated with many other functional or medically unexplained physical symptoms, such as chronic pain and fatigue, and are also found commonly in patients with emotional symptoms, such as depression and anxiety.
Further studies of the pathways to the development of pseudoneurological symptoms and why some symptoms develop in preference to others are required.
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June 1, 2007;
48(3):
230 - 238.
[Abstract]
[Full Text]
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C. M. Stonnington, J. J. Barry, and R. S. Fisher
Conversion Disorder
Am J Psychiatry,
September 1, 2006;
163(9):
1510 - 1517.
[Full Text]
[PDF]
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