Conversion Disorder (Functional Neurological Symptom Disorder)
CTEVT PSC curriculum300.11 · F44.xCTEVT PSC curriculum: on the official Psychosocial Counselor syllabus, can appear in the exam. Beyond curriculum: added for completeness, not examinable. A chip like 296.2x · F32 is the diagnosis code: the DSM-5's older ICD-9-CM number, then the ICD-10 "F-code" used in hospital records. Non-students can ignore all of these.
Real neurological symptoms, paralysis, seizures, blindness, mutism, that are incompatible with any neurological disease. The client is not pretending.
In plain words: Real symptoms that look neurological (fits, weakness, blindness, losing the voice) without a disease to explain them; the body is speaking.
- One or more symptoms of altered voluntary motor or sensory function.
- Clinical findings show incompatibility between the symptom and recognised neurological or medical conditions (e.g., a normal EEG recorded during a "seizure", though this alone does not exclude every form of epilepsy; tremor that stops when attention shifts).
- Not better explained by another medical or mental disorder.
- Clinically significant distress, impairment, or warrants medical evaluation.
Symptom types:
- Weakness or paralysis
- Abnormal movement
- Swallowing
- Speech
- Attacks or seizures (PNES)
- Anaesthesia or sensory loss
- Special sensory (vision, hearing)
- Mixed
DSM-5 dropped the old requirement to prove a psychological stressor, and "la belle indifférence" is not diagnostic.
| Epileptic seizure | Conversion (psychogenic non-epileptic) attack | |
|---|---|---|
| Onset | Sudden, any time: including sleep, alone | Gradual, usually with witnesses present |
| Movements | Rhythmic, synchronous jerking; stereotyped | Asynchronous thrashing, pelvic thrusting, side-to-side head shaking, arc de cercle |
| Eyes | Usually open or deviated | Usually closed, resist opening |
| Injury & incontinence | Side-of-tongue biting is fairly specific; falls and incontinence occur | Also occur; no single sign settles it, video-EEG does |
| Duration | Typically 1–2 minutes | Often prolonged, waxing-waning, >5 minutes |
| After the attack | Confusion, drowsiness (post-ictal) | Rapid recovery, may cry; recall variable |
| EEG | Epileptiform activity | Normal during attack |
This is a signature Nepali presentation: episodes of fainting, jerking, or possession-like states ("chhopne") in adolescent girls, often spreading through a school classroom or hostel within hours: mass conversion / mass psychogenic illness, repeatedly reported in Nepali districts. The National Mental Health Survey 2020 found dissociative disorder in 1.0% of adults currently and somatic symptom disorder in 0.5%. See Nepal in numbers.
Respond by separating affected students calmly, avoiding dramatic audiences, ruling out real medical causes, and working with the community's spiritual explanation rather than against it. Never announce "it is all in her mind": the symptom is real, involuntary, and treatable, and the family's cooperation is your main instrument.
Refer first-ever seizures for neurological work-up always.
Also in this chapter: Somatic Symptom Disorder (300.82/F45.1): one or more distressing bodily symptoms plus excessive thoughts, anxiety, or time devoted to them, persistent (typically >6 months); the symptom may or may not be medically explained: what is disordered is the response to it. Illness Anxiety Disorder (300.7/F45.21): preoccupation with having a serious illness, with minimal or no somatic symptoms; checking or avoidance; ≥6 months.
A worked example: A 35-year-old named Deepa has episodes of sudden collapse at school assemblies. Teachers assume she is pretending, but a counselor notes that her episodes last over ten minutes with eyes closed and gradual recovery, consistent with a conversion attack rather than epilepsy. A video-EEG confirms the diagnosis and the counselor begins psychoeducation about how stress converts into symptoms.