Conversion disorderMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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429 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Acute anxiety Acute psychosis Agitation:behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp54

Immediate safety and stabilization

›Stabilization priorities

›Airway compromise

›Stridor

›Inability to protect airway

›Breathing compromise

›Hypoxemia

›Hypercapnia

›Circulatory compromise

›Hypotension

›Shock physiology

›Glucose

›Hypoglycemia

›Hyperglycemia

›If seizure-like activity and convulsive status epilepticus not excluded, follow status epilepticus pathway

›ACEP seizure clinical policy Level A treatment escalation after appropriately dosed benzodiazepines

›Avoid iatrogenic escalation when functional seizure features strongly supported

Time-critical exclusions

›Cannot-miss mimics

›Acute ischemic stroke

›Last known well time

›Persistent focal deficit pattern

›Intracranial hemorrhage

›Thunderclap headache

›Anticoagulant use

›CNS infection

›Fever

›Neck stiffness

›Spinal cord compression

›Saddle anesthesia

›Urinary retention

›Convulsive status epilepticus

›Continuous convulsions 5 minutes or longer

›Recurrent convulsions without recovery

›Toxicologic syndrome

›Sympathomimetic toxidrome

›Anticholinergic toxidrome

Key concepts

›Functional neurological symptom disorder

›DSM-5 framework based on positive clinical features and incompatibility with recognized neurological disease

›Symptoms not intentionally produced

›Distinct from malingering

›Distinct from factitious disorder

›Functional seizures

›VEEG gold standard for documented diagnosis

›Benzodiazepines and antiseizure medications lack evidence of benefit for functional seizures without epilepsy

Communication and environment

›Therapeutic stance

›Respectful language

›Avoid stigmatizing behavior

›Avoid implying symptoms are fabricated

›Calm low-stimulation setting

›Reduce crowding

›Reduce repeated provocative exams

›Early framing

›Symptoms real and common

›Brain network functioning problem

›Treatable condition

02History/hx52

Presentation pattern and context

›Symptom narrative

›Symptom type

›Weakness

›Sensory loss

›Speech disturbance

›Gait disturbance

›Tremor

›Seizure-like episodes

›Onset and time course

›Sudden onset

›Fluctuating course

›Episodic pattern

›Triggers and context

›Injury or illness trigger

›Migraine trigger

›Panic symptoms

›Sleep deprivation

›Functional impact

›Work or school impairment

›Driving risk

›Falls risk

Risk factors and comorbidities

›Associated factors

›Prior functional neurological symptoms

›Prior stroke-mimic evaluations

›Prior seizure evaluations

›Psychiatric comorbidity

›Anxiety disorder

›Depressive disorder

›PTSD history

›Substance use disorder

›Neurologic comorbidity

›Epilepsy

›Migraine

›Multiple sclerosis

›Trauma and adverse experiences

›Childhood adversity

›Recent interpersonal trauma

Functional seizure semiology

›Episode description

›Prodrome

›Dissociation

›Panic

›Ictal features

›Duration longer than typical generalized tonic-clonic pattern

›Eyes closed during event

›Asynchronous limb movements

›Pelvic thrusting

›Side-to-side head movements

›Post-event

›Rapid recovery

›Prolonged unresponsiveness without physiologic compromise

›Witness video availability

›Smartphone video review to support diagnosis

03Physical Exam/exam28

Neurologic exam and positive functional signs

›Exam strategy

›Full neurologic screen

›Cranial nerves

›Motor strength pattern

›Reflexes

›Sensory pattern

›Coordination

›Gait

›Internal inconsistency

›Give-way weakness

›Variability with distraction

›Functional weakness signs

›Hoover sign

›Hip extension weakness normalizes with contralateral hip flexion effort

›Hip abductor sign

›Functional tremor signs

›Entrainment

›Distractibility

›Functional gait signs

›Astasia-abasia pattern

›Marked variability between tasks

Red flags on exam

›Findings supporting organic neurologic disease

›Objective cranial nerve palsy

›New aphasia consistent with stroke syndrome

›Persistent unilateral hyperreflexia with clonus

›Sensory level

›True ataxia with consistent dysmetria

›Papilledema

04Differential Diagnosis/ddx31

Life-threatening and urgent mimics

›High-risk neurologic etiologies

›Acute ischemic stroke ICD-10 I63

›Transient ischemic attack ICD-10 G45

›Intracerebral hemorrhage ICD-10 I61

›Subarachnoid hemorrhage ICD-10 I60

›CNS infection ICD-10 G00 to G04

›Spinal cord compression ICD-10 G95.2

›Status epilepticus ICD-10 G40.901

›Toxicologic syndrome ICD-10 T36 to T50

Common neurologic and medical mimics

›Alternative explanations

›Epileptic seizure disorder ICD-10 G40

›Syncope ICD-10 R55

›Migraine with aura ICD-10 G43.1

›Multiple sclerosis relapse ICD-10 G35

›Vestibular neuritis

›Hypoglycemia ICD-10 E16.2

›Electrolyte disturbance

›Hyponatremia ICD-10 E87.1

›Hypocalcemia ICD-10 E83.51

›Drug effect

›Intoxication

›Withdrawal

Functional and related diagnoses

›Functional and behavioral diagnoses

›Functional neurological symptom disorder SNOMED CT Functional neurological symptom disorder

›Functional seizures ICD-10 F44.5

›Functional weakness ICD-10 F44.4

›Functional sensory symptoms ICD-10 F44.6

›Somatic symptom disorder ICD-10 F45.1

›Panic attack ICD-10 F41.0

›Factitious disorder ICD-10 F68.1

›Malingering ICD-10 Z76.5

05Laboratory Tests/lt26

Core tests guided by presentation

›Targeted labs

›Point-of-care glucose for altered awareness

›Glucose mmol/L

›Hypoglycemia threshold local protocol

›Electrolytes for weakness or seizure-like activity

›Sodium

›Calcium

›Magnesium

›Complete blood count for infection concern

›Leukocytosis

›Anemia

›Pregnancy test for reproductive-age patients

›Eclampsia consideration if seizure-like activity in pregnancy

›Toxicology when exposure suspected

›Alcohol level where clinically indicated

›Targeted drug levels when relevant

Tests sometimes used for seizure differentiation

›Post-event biomarkers

›Prolactin

›False positives and false negatives for differentiating functional vs epileptic seizures

›Lactate

›False positives and false negatives for differentiating functional vs epileptic seizures

›Creatine kinase

›False positives and false negatives for differentiating functional vs epileptic seizures

Medical clearance for psychiatric pathway

›Testing strategy

›Routine broad lab panels low yield in isolated psychiatric presentations

›ACEP psychiatric patient policy Level C against routine labs without clinical indication

06Diagnostic Tests/dt31

Scoring Systems

›Syndrome-specific tools

›Stroke pathway tools

›NIHSS for deficit description

›Do not use risk tools alone to rule out high-risk TIA per ACEP Level B

›Functional seizure diagnostic certainty framework

›Documented functional seizures requires VEEG capture of typical events

›Probable functional seizures when VEEG not feasible relies on history and semiology plus supportive testing

MRI

›MRI indications

›Stroke mimic with persistent deficit and nondiagnostic CT

›Diffusion-weighted imaging

›Posterior circulation concern

›Myelopathy concern

›Spine MRI with contrast when indicated

›Demyelination concern

›Brain MRI with MS protocol

›CT indications

›Acute focal neurologic deficit

›Non-contrast CT head for hemorrhage exclusion

›Head trauma

›CT head per decision rules and anticoagulant status

›Thunderclap headache

›CT head early presentation

›CTA head neck when clinically indicated

Ultrasound

›Point-of-care ultrasound adjuncts

›Alternative diagnosis support

›Cardiac POCUS for tamponade physiology in shock

›Lung POCUS for pneumothorax in sudden dyspnea

›Pregnancy POCUS for intrauterine pregnancy when indicated

›Limitations

›Does not diagnose functional neurological symptom disorder

›Used to exclude urgent mimics

07Disposition/dispo29

Level of care and consultation

›Admission indications

›Persistent objective neurologic deficit

›Uncertain diagnosis after appropriate evaluation

›Recurrent events with injury risk

›Severe functional impairment without safe supports

›Active suicidal ideation requiring safety planning and psychiatric care

›ICU indications

›Airway risk

›Ongoing convulsive activity with epileptic status concern

›Hemodynamic instability

›Consultation targets

›Neurology

›First presentation with stroke mimic features

›Functional seizure diagnostic pathway planning

›Psychiatry

›Severe anxiety or depression impairing function

›Comorbid trauma-related disorder

›PT and OT

›Motor FND rehabilitation planning

Discharge criteria and follow-up

›Safe discharge features

›Time-critical mimics reasonably excluded

›Normal vital signs

›Patient understanding of diagnosis framing

›Clear follow-up plan

›Neurology or FND clinic referral

›Psychotherapy referral

›PT referral

›Driving and safety counseling

›Regional driving rules for episodic loss of awareness

08Treatment/t77

Diagnosis delivery and engagement

›Communication framework

›Diagnostic label and rationale

›Clear explanation

›Empathetic supportive tone

›Positive signs explanation

›Inconsistency and distractibility as exam-based evidence

›Hoover sign explanation when present

›Shared decision-making

›Patient goals

›Treatment priorities

Acute functional seizure episode care

›Episode management

›Safety measures

›Side positioning

›Protect from injury

›Avoid noxious stimuli

›Physiologic monitoring

›Pulse oximetry

›Glucose check if altered awareness

›De-escalation

›Calm verbal grounding

›Reduce audience

›Medication strategy

›Avoid benzodiazepines as routine treatment for functional seizures without epilepsy due to iatrogenic harm risk

›Avoid antiseizure medications for functional seizures without epilepsy

›Action plan

›Written episode plan for patient and caregivers

Rehabilitation and psychotherapy

›Evidence-based pathways

›Psychological interventions

›Referral to psychological therapy for functional seizures Level B AAN

›CBT-informed approach

›Trauma-focused therapy when indicated

›Physical-based therapies

›Motor retraining PT for functional weakness and gait disturbance

›OT for functional task restoration

›Multidisciplinary care

›Coordinated neurology and mental health collaboration

›Non-specialist symptom support per NICE quality standard

Pharmacotherapy for comorbid conditions

›Medication principles

›Target comorbid psychiatric disorders

›Anxiety disorder

›Depressive disorder

›PTSD

›Avoid medication as primary treatment for functional symptoms

›Limited evidence for direct benefit in functional seizures

›SSRI examples

›Sertraline

›Starting dose 25 mg PO daily

›Increase to 50 mg PO daily after 1 week if tolerated

›Typical target 50 to 200 mg PO daily

›Escitalopram

›Starting dose 5 mg PO daily

›Increase to 10 mg PO daily after 1 week if tolerated

›Typical target 10 to 20 mg PO daily

›Sleep and anxiety short-term cautions

›Benzodiazepines

›Dependence risk

›Cognitive impairment risk

If epileptic seizure cannot be excluded

›Status epilepticus pathway

›First-line benzodiazepine therapy

›Lorazepam IV

›Class I recommendation in Neurocritical Care Society guidance summary

›AES guideline supports benzodiazepines as established efficacious Level A

›Midazolam IM

›Class I recommendation in Neurocritical Care Society guidance summary

›AES guideline supports IM midazolam Level A without IV access

›Diazepam IV or PR

›Class IIa recommendation in Neurocritical Care Society guidance summary

›Second-line antiseizure agent if refractory

›Fosphenytoin

›ACEP seizure clinical policy Level A second-line option

›Levetiracetam

›ACEP seizure clinical policy Level A second-line option

›Valproate

›ACEP seizure clinical policy Level A second-line option

›De-escalation when functional seizures confirmed

›Stop further benzodiazepine escalation for functional seizures

›Taper antiseizure medications if no epilepsy indication

09Special Populations/sp29

Pregnancy

›Pregnancy considerations

›Key differentials

›Eclampsia

›Hypertension

›Proteinuria or end-organ signs

›Stroke and cerebral venous thrombosis

›Diagnostic strategy

›Obstetric consultation when seizure-like activity in pregnancy

›Avoid delayed treatment of eclampsia when suspected

›Treatment cautions

›Avoid unnecessary antiseizure medications if functional seizures strongly supported

Geriatric

›Older adult considerations

›Higher organic disease probability

›Stroke mimic evaluation threshold lower

›Medication adverse effects risk higher

›Delirium screening

›Infection trigger

›Medication toxicity

›Disposition planning

›Falls risk mitigation

›Home supports assessment

Pediatrics

›Pediatric considerations

›Family involvement

›Family engagement improves outcomes for functional seizures Level B AAN pediatric family involvement

›School and social context

›Bullying

›School avoidance

›Safeguarding

›Abuse concern assessment when indicated

10Background/b33

Epidemiology

›Frequency and settings

›Incidence estimates

›10 to 22 per 100000 per year

›Prevalence estimates

›80 to 140 per 100000

›Neurology service burden

›Approximately one in six new neurology outpatient presentations

›Stroke mimic contribution

›Stroke code cohorts include substantial stroke mimics with functional etiologies reported

›Functional seizure diagnostic delay

›Average delay approximately 7 years

Pathophysiology

›Mechanistic framework

›Abnormal brain network functioning

›Altered attention and expectation effects

›Altered motor control prediction signaling

›Triggering events

›Injury or illness

›Migraine

›Psychological stressor not required by DSM-5 framework

›Symptom reinforcement

›Avoidance learning

›Fear conditioning

Therapeutic Considerations

›Treatment rationale

›Positive diagnosis improves engagement

›Clear explanation platform for treatment

›Multidisciplinary rehabilitation

›PT motor retraining

›CBT or other psychotherapy

›Medication stewardship

›Avoid antiseizure medications without epilepsy indication

›Avoid benzodiazepines as routine for functional seizures due to iatrogenesis risk

›Non-specialist support

›Symptom management support in non-specialist care per NICE quality standard

11Patient Discharge Instructions/pdi26

Copy discharge instructions

›Discharge guidance

›Diagnosis explanation

›Functional neurological symptom disorder

›Symptoms real and common

›Nervous system functioning problem

›What to do during an episode

›Move to safe place

›Lie on side if shaking or faint

›Slow breathing and grounding

›Remove audience and reduce stimulation

›Follow-up plan

›Neurology referral

›Psychotherapy referral

›PT referral for weakness or gait symptoms

›Return to emergency care now

›New one-sided weakness that does not improve

›New trouble speaking or understanding

›Severe new headache

›Fever with stiff neck

›New loss of vision

›Chest pain or severe shortness of breath

›Seizure-like activity lasting 5 minutes or longer

›Repeated seizure-like episodes without recovery

›Serious injury during an episode

›Safety counseling

›Driving restrictions based on local rules for episodes of impaired awareness

12References/r13

Guidelines and key evidence

›Core sources

›AAN Management of Functional Seizures Practice Guideline Clinician Summary 2025

›NICE Quality Standard QS198 Functional neurological disorders in adults 2021

›ACEP Clinical Policy Critical Issues in the Management of Adult Patients Presenting to the ED With Seizures 2024

›Neurocritical Care Society Guidelines for the Evaluation and Management of Status Epilepticus 2012

›AES Evidence-Based Guideline Treatment of Convulsive Status Epilepticus 2016

›Background and reviews

›StatPearls Functional Neurologic Disorder updated 2023

›Practical Neurology Diagnosis of Functional Movement Disorder 2022

›Stroke Functional Neurological Disorder review 2020

›JNNP Incidence and prevalence of functional neurological disorder 2025

›Cleveland Clinic Journal of Medicine PNES empathetic approach 2022

›WHO ICD-10 F44.5 dissociative convulsions

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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