Never Have I Ever beautifully portrays Functional Neurological Symptom Disorder (Conversion Disorder). Spoiler alert: this depiction appears only in the first ten minutes of episode one. The series accurately illustrates how Devi’s lower limbs become paralyzed following her father’s death, reflecting the typical onset of FND symptoms, which often emerge suddenly after significant emotional or physical distress or psychological conflict.
Previously known as Conversion Disorder, this condition was once believed to be purely psychological, with psychological problems "converted" into physical symptoms—a notion reflected in the term itself. In the series, Devi's friends demonstrate appropriate support by motivating and reassuring her, affirming that her symptoms are genuine rather than feigned. This education and reassurance align with effective treatment strategies, which emphasize providing support rather than suggesting a serious medical condition.
Devi frequently consults her psychologist to discuss her fears, though much of their conversation focuses on her high school issues. The psychologist encourages her to address her father’s death and to express her grief, including through a grief journal. Cognitive Behavioral Therapy (CBT) is typically the first-line treatment for this disorder. Symptoms of conversion disorder generally persist for days to weeks and may resolve suddenly.
The DSM-5 describes "la belle indifference" as a characteristic lack of concern about the nature or implications of the symptoms, which supports the diagnosis of conversion disorder. This is evident in the series, where Devi does not display overt distress about her paralysis. Even when she regains her ability to walk, her reaction is subdued, contrasting with the expected exuberance.
The writer, @mindykaling, has meticulously addressed every aspect of conversion disorder—from its causes and diagnosis to its treatment and prognosis. I am impressed by the accuracy of this portrayal and wonder if extensive research was undertaken. Outstanding work!
WHAT IS FND?
• It is a disorder in which a person experiences blindness, paralysis or other symptoms affecting the nervous system that cannot be explained.
• It is a medical condition in which there is a problem with the functioning of the nervous system and how the brain and body send and/or receives signals.
INCIDENCE AND INHERITANCE
2 to 5 individuals per 1,00,000 patients per year.
It is not thought that there is a single gene responsible for the development of conversion disorder. In most cases, only one person is identified in a single-family.
FND is more likely to affect women than men for most symptoms.
SYMPTOMS AND SIGNS
1.Motor:
Functional limb weakness/paralysis.
Functional movement disorders; including tremor, spasms (dystonia), jerky movements (myoclonus) and problems walking (gait disorder)
2.Sensory:
Numbness, tingling, or pain in the face. Functional visual symptoms; including loss of vision or double vision.
3.Episodes of altered awareness:
Dissociative (non-epileptic) seizures, blackouts, and faints: these symptoms can overlap and can look like epileptic seizures or faints (syncope).
La belle indifference is defined in DSM-5 as a “lack of concern about the nature or implications of the symptom” and is listed as an associated feature supporting the diagnosis of conversion disorder. Theories suggesting frontal lobe hypoactivation as an explanation for apathy and indifference have also been proposed.
CAUSES
The exact cause of conversion disorder is not well understood. Some researchers believe that conversion disorder is most common after instances of physical or psychological stressors. It may be that symptoms of the disorder allow affected individuals to provide a physical outlet to the stress in their lives. In other instances, affected individuals do not seem to have a stressor that is causing the symptoms. In these cases, the cause of conversion disorder is unknown.
Research into the cause of conversion disorder has found that the brain imaging of some individuals with the disorder shows increased or reduced blood flow to certain areas of the brain. If areas of the brain that are responsible for communication with other body parts have reduced blood flow, this may cause neurological symptoms associated with conversion disorder. It is possible that these changes in blood flow may be caused by the brain receiving information about physical or emotional stressors.
Regardless of the cause of the disorder, it is important to remember that the symptoms are very real; affected individuals are not faking symptoms of the disorder.
DIAGNOSIS
DSM-5 lists these criteria for conversion disorder (functional neurological symptom disorder):
• One or more symptoms that affect body movement or your senses
• Symptoms can't be explained by a neurological or other medical condition or another mental health disorder
• Symptoms cause significant distress or problems in social, work, or other areas, or they're significant enough that medical evaluation is recommended.
THERAPIES
Physical therapy: There is some evidence from clinical trials that physiotherapy designed specifically for FND can be helpful for some patients.
Psychological therapy: Cognitive Behavioral Therapy(CBT)is generally the first line of treatment for patients with dissociative (non-epileptic) seizures or attacks as part of their FND and is supported by clinical trials. For some patients, it is helpful to look more widely at thoughts, emotions, and experiences that could have played a role in the development of symptoms. For those patients without anxiety and depression, psychological therapy may still be useful in regaining confidence.
Occupational therapy: It assists patients in finding adaptations and regaining confidence in their ability to carry out daily activities in the home or workplace.
Speech therapy: For patients with speech symptoms as part of FND, speech therapy is an important part of treatment.
Medications
Medications are not effective for functional neurologic disorders, and no drugs are approved by the Food and Drug Administration specifically as a treatment. However, medications such as antidepressants may be helpful if you also have depression or other mood disorders, pain, or insomnia.
PROGNOSIS
Symptoms of conversion disorder usually last for days to weeks and may suddenly go away. Symptoms of conversion disorder get better with reassurance and time. However, up to one in four people may show a recurrence or new symptoms later.
Individuals may be more likely to have long-lasting symptoms or develop a new conversion disorder if:
• They delay seeking treatment
• The symptoms come on slowly or don’t improve quickly
• They have serious psychiatric disorders
• They have tremors or seizures not caused by epilepsy
One way of thinking about FND is looking at it as a bit like a ‘software’ problem on a computer. The ‘hardware’ is not damaged but there is a problem with the ‘software’ and so the computer doesn’t work properly.
DISCLAIMER : This article is intended for education purposes only. It is not a substitute for a Physician's judgement.
REFERENCES:
Berger FK, Zieve D, and Conaway B. Conversion disorder. MedlinePlus. November 18, 2016;
https://my.clevelandclinic.org/health/diseases/17975-conversiondisorderin-adults
Marshall SA, Landau ME, Carroll CG, Schwieters B, and Llewellyn A. Conversion disorders. Medscape
Vermeulen M and Willems MH. Conversion disorder: from DSM IV to DSM 5 or from a psychiatric to a neurological diagnosis. Tijdschrift Voor Psychiatrie. 2015; 57(8):569-576.
https://rarediseases.info.nih.gov/diseases/6191/conversiondisorder#ref_1 3716
Gurses N, Temucin CM, Lay Ergun E, Ertugrul A, Ozer S, and Demir B. Evoked potentials and regional cerebral blood flow changes in conversion disorder: a case report and review. Turkish Journal of Psychiatry. Spring 2008; 19(1):101-107. https://www.ncbi.nlm.nih.gov/pubmed/18330748.
Conversion disorder. National Organization for Rare Disorders. 2003; https://www.ncbi.nlm.nih.gov/pubmed/18330748
Owens C and Dein S. Conversion disorder: the modern hysteria. Advances in Psychiatric Treatment. 2006; 12:152157. http://apt.rcpsych.org/content/aptrcpsych/12/2/152.full.pdf.
American Psychiatric Association. (2013). Diagnostic and statistical manual
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