Mr. Smith is Falling Every Day: Conversion Disorder in an Elderly Man

Elders experience many life changes and major events, including the death of friends or loved ones, which can manifest as physical symptoms. When an elderly patient has symptoms that cannot be explained by a physical or neurological evaluation, an underlying psychological cause should be considered. Conversion disorder is a psychiatric phenomenon marked by such unexplained symptoms, but it is not easy to distinguish this condition from other disorders or malingering. The authors use a case report of an elderly man with a history of frequent falls to illustrate how observations from a detailed history and physical examination led them to a diagnosis of conversion disorder. The patient’s falls were curtailed without the use of added medication, after addressing his unmet psychosocial needs and establishing a simple care plan with his family. This case report underscores the value of understanding conversion disorder, how to diagnose it, and how to manage it when patients present with medically unexplained symptoms.

Key words: Conversion disorder, falls, medically unexplained symptoms, elderly, malingering
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In the United States, falls are the leading cause of injury-related visits to emergency departments.¹ They are also a leading cause of accidental death in older adults, and are associated with increased morbidity and mortality in this age group.^1,2 Therefore, preventing and reducing falls among elders is vitally important. Conducting a fall risk assessment for elders is an exhaustive process because there can be many risk factors across these persons’ medical, psychiatric, and social domains.³ Elders residing in long-term care (LTC) settings are at high risk of falls and fall-related injuries due to a number of predisposing factors, including unsteady gait, frailty, poor vision, and environmental hazards. Psychiatric causes, such as dementia, depression, and other common mental illnesses can also contribute to fall risk. The challenge to clinicians arises when patients present with sensory or motor symptoms contributing to falls that cannot be explained with a medical evaluation.

Conversion disorder is considered a somatoform disorder in which psychological needs, conflicts, or stress can manifest as physical symptoms.^4-6 Patients with conversion disorder may present with unexplained motor or sensory symptoms or deficits, such as numbness, blindness, paralysis, or convulsions, despite no physical or neurological cause.^4,7 At times, symptoms of conversion disorder can be difficult to distinguish from factitious disorders or malingering. There is a paucity of data on the prevalence and epidemiology of conversion disorder, which may cause the condition to be underrecognized or mistaken for other neurological or factitious disorders, causing it to be treated inappropriately, especially among older adults. We present a clinical scenario demonstrating the diagnosis and management of conversion disorder in an elderly man with a history of frequent falls. To aid clinicians in recognizing conversion disorder, the case presentation is followed by a discussion on how to diagnose conversion disorder and differentiate its symptoms from an organic disease, how to deliver the diagnosis to patients, and how to appropriately manage the condition.

Case Presentation 

An 80-year-old white man had been living with his wife of more than 50 years in an independent senior community in Florida, where he had cultivated meaningful friendships and social support. When his wife died, he relocated to his hometown in Michigan to be near his five daughters. The man had a history of frequent falls, and shortly after moving in with one of his daughters, he fell and fractured his clavicle. His four other daughters were also involved in his care. When his daughters became unable to care for his physical needs at home, they moved him to an assisted living facility, where he resided for a year. He said that he enjoyed socializing with staff and residents at the facility, but that he missed playing bridge, as the other residents did not know how to play, and wished he could see his family more often.

The resident was referred to a senior health center outpatient clinic for evaluation at the request of his family and facility staff when his falls had continued to increase in frequency. He said that he was not concerned about these falls and simply wanted to be evaluated for pain in his ribs from his most recent fall. One of his daughters accompanied him to the clinic and helped to provide his medical history.

Medical History

The patient had a history of multilevel degenerative disc disease of the spine, persistent pain syndrome, hypertension, and mild Parkinson’s disease. He had undergone several operations on his spine, and both knees had been replaced 15 years earlier. The patient reported no hallucinations, dysuria, urinary frequency, dizziness, insomnia, anorexia, diarrhea, or constipation. He stated that his appetite was good and that his weight had not changed. Except for the aforementioned clavicle fracture, he had not broken any other bones while falling.

The patient reported that his persistent pain syndrome had been well controlled since he started taking narcotics, and the pain medication also had helped to reduce the frequency of the falls; however, the patient did not appear to be concerned about the falls. His medications included carbidopa/levodopa 25 mg/100 mg daily; aspirin, 325 mg daily; oxycodone, 5 mg three times daily; docusate, 200 mg daily; and multivitamins, one tablet daily. He took no other medications or supplements and had no history of substance abuse, alcohol use, or smoking.

The patient’s falls occurred at no specific time of the day and were not related to mealtimes or activities. He was aware of falling but said he never lost consciousness. He also stated that he did not feel any sense of confusion or memory loss preceding or following these falls, and he was able to describe in vivid detail the activity he was involved in at the time. He commented, “Sometimes I do not even tell anybody; there are so many of them.” His daughter appeared visibly upset by this comment and reacted by reiterating the importance of prompt notification of such events, saying, “We are worried about you, Dad. You have to call us when these things happen.” The patient dismissed his daughter’s concern and said, “You all have families and work to attend to.” The patient appeared to be indifferent, as he could not describe any factors that exacerbated or decreased the number of falls (aside from his pain medication). On several occasions, attendants at the assisted living facility found him on the floor of his room; however, he did not recall any significant details of these events. There were no witnessed falls by his family or facility staff, except for what his daughter described as “bad balance.” She also recalled that he “almost falls” when the family takes him out for dinner or other trips. Two days before arriving at the outpatient clinic, the patient fell on the toilet and claimed to have hurt his ribs. He reported pain in his right lower rib cage, which he rated a 10 out of 10 on the Faces Pain Scale.

Physical Examination

The patient’s vital signs were normal, his oxygen saturation was 96% on room air, and he was in no respiratory distress. A chest examination revealed no splinting or paradoxical chest wall movements, but slight tenderness of the lower right rib area was evoked on palpation. No bruising or swelling was noted on the chest or elsewhere on the skin. A cranial computed tomography scan showed no abnormalities. A chest radiograph revealed no change in his spinal osteoarthritis, which had been diagnosed on a radiograph that had been taken during a work-up in the emergency department for his most recent fall. As a result of his spinal osteoarthritis, he had reduced range of motion in his spine and knees. No tremors were noted. Laboratory assessments, including a complete blood count, urinalysis, and comprehensive metabolic panel were within normal limits.

During the physical examination, the patient was alert, awake, and oriented to time and place. He preferred sitting in a wheelchair, but was able to stand and walk 20 feet for about 10 seconds with a walker. His scores on the Mini-Mental State Examination and Clock Drawing Test indicated normal cognitive function, and his score on the Geriatric Depression Scale was also normal. He was in no apparent distress during the examination, despite making several comments about having a lot of rib pain, which he only mentioned when his daughter was in the room. His mood was euthymic and his affect was noticeable for being indifferent and disconnected to his presenting pain symptoms.

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Diagnosis, Intervention, and Outcome

The patient’s history and the results of his physical examination led us to consider a nonphysical cause of his falls. The absence of any evidence of a physical cause of this symptom and a lack of any new finding on imaging studies pointed strongly toward a psychological cause. Additional information gleaned from his social history regarding his feelings of isolation and inability to socialize with other residents was indicative of a significant unmet psychosocial need. His notable ambivalent dynamics with his daughter were suspected as the trigger for his psychological conflict. The patient’s disconnect with the symptoms strongly supported a presumptive diagnosis of conversion disorder. After reporting a fall, he would be visited by family members, who would console and care for him; thus, this attention was a secondary gain from his falls. In addition, his family members and the facility staff never witnessed the falls, and there were rarely any visible injuries, further pointing to a nonphysical cause.

To better assess the cause of the falls, we separately interviewed the patient and his daughter. His daughter expressed her family’s frustration with the current situation, commenting, “We were not expecting all this. We can’t even go out of town, and he wants us around all the time.” She added that her father had wanted to move from Florida after his wife died to be with his children. “He lived with me for the first few months until we had to move him to an assisted living facility, as he needed more help than we could provide at home.” His daughter admitted feeling guilty and helpless about her father’s situation, and she described him as being “unhappy but accepting” of the loss of his independence. She also said there had been a definite increase in the reports of his falling since he moved to the assisted living facility, and she expressed doubts about having moved him there.

On the other hand, the patient expressed satisfaction with his current living arrangements. “That facility is a great place, but I wish I could see my family more,” he said. He was asked directly about the falls and a possible link with any anxieties. He could not establish a plausible link and exhibited indifference toward the falls by saying, “My body just does not match my mind anymore.” He repeated one comment several times: “I know my daughters are all busy with their lives; they cannot be with me all the time.”

After the separate interviews, the patient and his daughter were brought back together, and the following recommendations were incorporated into a revised care plan based on the concerns they had both expressed: (1) scheduled visits by each daughter every week; (2) a once weekly visit to a local bridge club, facilitated by his daughters; (3) referral for a local support group, if available; and (4) referral for psychotherapy to address the patient’s unacknowledged grief.

Follow-up visits to the clinic at 2, 4, and 12 weeks showed remarkable progress. The patient, the facility staff members, and his family reported that he had experienced no falls since the care plan had been put in place. His family was adhering to the recommended weekly visits. The patient refused to see a therapist for cognitive behavioral therapy, but he agreed to return for brief scheduled follow-up visits to the clinic.

Discussion

According to the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV-TR)⁴, conversion disorder comprises one or more symptoms or deficits that affect voluntary motor or sensory function, suggestive of a neurological or other general medical condition, but with distinct presentations and findings that help differentiate it from an organic disease (Table 1^8-17). There are four types of conversion disorder: those with motor symptoms or deficits; those with sensory symptoms or deficits; those with pseudoseizures; and those with a mixed presentation.⁴ Our case patient’s falls likely resulted from ataxia, syncope, or both. Because conflicts or other stressors often precede the initiation or exacerbation of symptoms or deficits in conversion disorder, psychological factors are judged to be associated with this condition.⁴ It is important to determine that these symptoms or deficits are not intentionally produced, a key factor that differentiates conversion disorder from a factitious disorder or malingering (Table 2¹⁸).

The medical literature on the neurological epidemiology of conversion disorder is scant. There is emerging research to identify cerebral causes of conversion disorder using data from functional imaging studies; however, consistent evidence is lacking, which may be attributed to small sample sizes, varying clinical presentations, and differences among experimental paradigms.¹⁹ A full discussion of the etiology and epidemiology of conversion disorder is beyond the scope of this article. 

Prevalence of Conversion Disorder

Information on the prevalence of conversion disorder is limited, partly because of changes to the nomenclature of this disorder over time, the complexities of the diagnostic process, and varying prevalence rates depending on the composition of the population studied and whether researchers report the frequency of conversion symptoms or the full diagnosis of the syndrome. According to the DSM-IV, the lifetime prevalence of conversion disorder is not known, yet it estimates the prevalence to range between 0.01% to 0.5% of the general population, and the condition is more commonly seen in women, with a female to male ratio ranging from 2:1 to 10:1.⁴ A 2011 literature review by Feinstein¹⁹ indicated that 20% to 25% of patients in general hospital settings have individual symptoms of conversion disorder, and 5% of patients in this setting meet the criteria for the full syndrome.

The prevalence of conversion disorder is likely to be higher in neurology settings than in general care settings. The rate of referral to neurology outpatient clinics due to medically unexplained symptoms is remarkably high at 30% to 60%.^20-22 In a prospective cohort study by Carson and colleagues,²⁰ one-third of new referrals to general neurology clinics have symptoms that are not well explained by identifiable neurological disease. Studies on the incidence of admissions related to unexplained medical symptoms have found a higher number of elders being admitted to general medical floors and other hospital services.²³ The considerable variability in prevalence according to clinical settings suggests a heightened diagnostic vigilance from clinicians where appropriate.Differential Diagnosis

The differential diagnosis of conversion disorder can be a long and exhaustive process. The absolute diagnosis can only be reached through a process of elimination. The diagnostic work-up requires a careful, systemic approach to avoid unnecessary, painful, and invasive testing. 

Somatoform disorders are a group of psychiatric disorders characterized on the basis of external somatic symptoms. This group includes somatization disorder, hypochondriasis, body dysmorphic disorder, and conversion disorder. These disorders are characterized by physical problems that appear to be medical in origin but that cannot be linked to a physical cause. To meet the criteria of somatoform disorders, the physical symptoms must be serious enough to interfere with patient’s functioning and must not be in the patient’s voluntary control.

We recommend the following systemic approach to obtain the most relevant clinical information for diagnosing conversion disorder in a geriatric patient suspected of having this condition:

1.     Obtain a detailed personal, sexual, and social history;

2.     Assess for secondary gains and motivations;

3.     Explore unmet psychosocial needs;

4.     Obtain a thorough family history;

5.     Conduct basic laboratory testing for common treatable conditions;

6.     Perform imaging studies to rule out any serious life-threatening illnesses, such as tumors or malignancy;

7.     Avoid negative reinforcement;

8.     Follow-up to rule out other coexisting diseases that may be contributing to the symptoms so that unnecessary therapeutic interventions are avoided;

9.     Employ a multidisciplinary approach;

10.  Set up a psychiatry consultation;

11.  Schedule frequent follow-up visits with the patient to provide reassurance.

Although exhaustive work-ups should be avoided, laboratory testing should focus on excluding some common clinical entities, including electrolyte disturbances, hypoglycemia, hyperglycemia, renal failure, systemic infection, and the presence of toxins or drugs.²⁴ A chest radiograph may be considered to diagnose an occult neoplasm, and computed tomography or magnetic resonance imaging may be performed to rule out a space-occupying lesion in the brain or spinal cord.

Conversion disorders are quite challenging to diagnose and becomes even more challenging when malingering is a possibility. In elderly patients, a diagnosis of conversion disorder is further complicated by the burden of coexisting chronic diseases and of any cognitive impairment. A clinician’s strategy should be a dual investigation of physical and psychological causes, which can be gleaned from skillful history taking and a thorough physical examination. Moreover, clinicians should make every attempt to understand the nature of a patient’s motivation, whether it is conscious or unconscious, and any secondary gains the patient may be achieving through his or her symptoms. Malingerers are both conscious of their motivation and their secondary gains, as opposed to patients with conversion disorder, who are unconscious of their motivation (Table 2). An early psychiatric consult is highly recommended, particularly when it is unclear whether the patient has a conversion disorder or is a malingerer. Specialized techniques, such as hypnosis, or other tests can be undertaken to differentiate malingering from conversion disorders, although the success of these special therapies are still being investigated.¹⁹

Management and Treatment

Conversion disorder implicates some role of the unconscious in the pathophysiology of this condition.^25-27 Patients suffering with this disorder are unable to understand this inner conflict, which is occurring on an unconscious level. Therefore, the aim of therapy should be directed at achieving resolution of the conflict through support that helps them become aware of their psychological conflict. Once patients establish the connection between their symptoms and their psychological need, their symptoms may improve. Above all, we would stress three tenants of treating patients with conversion disorder: avoid invasive diagnostic and therapeutic interventions; avoid discussing with patients the possible diagnosis on the first encounter; and avoid giving patients the impression that you feel there is nothing wrong with them. Table 3^25,28,29 provides further guidance on tactfully presenting the diagnosis of conversion disorder to patients and key points for managing the condition.

A multidisciplinary approach to the treatment of conversion disorder is beneficial and psychiatric consultation is generally warranted.²⁷ A psychiatrist or psychologist can use many strategies to help these patients. Cognitive behavioral psychotherapy, which examines the patient’s symptoms and teaches techniques to help him or her better cope and alleviate the symptoms (eg, through using biofeedback techniques), can be beneficial. Other potential therapies include insight-oriented supportive therapy, which uses support to help the patient gain insights into his or her condition and possible triggers; psychodynamic therapy, which is generally used further in the treatment process and may provide the patients with additional insights on his or her condition; and family therapy, which emphasizes interactions and communication within the family, rather than only focusing on the individual patient.²⁵ A physical therapist consultation may be helpful for those with motor or gait symptoms.²⁹ Regardless of which therapies are implemented, the most important element is for all healthcare providers to be supportive and to foster a good relationship with the patient.

Follow-up and Prognosis

Spontaneous resolution of conversion disorder is not uncommon²⁵; however, frequent follow-up and monitoring should be an important part of the ongoing care plan for these patients. Recurrence of the same or different conversion symptoms have an incidence rate as high as 25% in 15-year follow-up studies.²⁵ Numerous factors contribute to a favorable prognosis, including onset and duration of symptoms, high intelligence, good premorbid functioning, and good general health.^25,30 Some symptoms and clinical presentations linked to a poor prognosis include pseudoseizures (psychogenic nonepileptic seizures), undiagnosed personality pathology, concomitant medical illnesses, and poor perception of well-being.

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Conclusion

Elders live under the constant threat of loss in all domains of their life. The loss of family and friends related to disease and old age is made even more profound by their own declining physical capabilities. Unexpected and often unwelcome changes in their living situation can further compound this sense of losing control. The level of distress and the conflicting emotions generated are often the underlying factors in anxiety and depressive disorders and predispose elders to existential angst. Our case patient lost his wife, followed by his home and friends, all within a period of 2 years. Family members who came in contact with him after many years were overwhelmed by the burdens of caregiving. That distress was compounded by the dynamics between the patient and his family based on perceived guilt and assumed responsibility for care.

Unexplained medical symptoms in elders warrant exploration into the possibility of unmet psychosocial needs, as occurred with the case patient. Differentiating between conversion disorder and factitious illnesses poses a clinical challenge. The psychological basis of each disorder is different; thus, knowledge of these differences is helpful in the diagnostic work-up of patients with unexplained symptoms. Prompt diagnosis can save the patient from unnecessary medical tests and from polypharmacy, while meeting his or her emotional needs and perhaps relieving those symptoms, as we have illustrated in this case report.

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Disclosures:

The authors report no relevant financial relationships.

Address correspondence to:

Raza Haque, MD

B111 w Clinical Center

East Lansing, MI 48824-1313

raza.haque@hc.msu.edu