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Systematic review of misdiagnosis of conversion symptoms and “hysteria”

BMJ 2005; 331 doi: (Published 27 October 2005) Cite this as: BMJ 2005;331:989
  1. Jon Stone, consultant neurologist (Jon.Stone{at},
  2. Roger Smyth, consultant psychiatrist1,
  3. Alan Carson, consultant neuropsychiatrist1,
  4. Steff Lewis, medical statistician1,
  5. Robin Prescott, director, medical statistics unit1,
  6. Charles Warlow, professor of medical neurology1,
  7. Michael Sharpe, professor of psychological medicine and symptoms research1
  1. 1 School of Molecular and Clinical Medicine, University of Edinburgh, Edinburgh EH4 2XU
  1. Correspondence to: J Stone
  • Accepted 16 August 2005


Objective Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as “conversion” symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging.

Design Systematic review.

Data sources Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists.

Review methods We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data.

Results Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies.

Conclusions A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.


  • Contributors JS initiated the study. JS and RS designed the study. JS, RS, AC, CW, and MS carried out data extraction. SL and RP provided statistical advice. All authors participated in writing the manuscript. MS is the guarantor.

  • Funding JS was supported by the chief scientist office, Scotland.

  • Competing interests None declared.

  • Ethical approval Not required.

  • Accepted 16 August 2005
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