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La Belle Indifference

Editor: Nihit Kumar Updated: 12/9/2022 11:39:49 AM

The term “la belle indifference” is a French term that translates to “beautiful ignorance.”[1] La belle indifference is defined as a paradoxical absence of psychological distress despite having a serious medical illness or symptoms related to a health condition.[2] This condition is most commonly associated with conversion disorder (CD). According to the Diagnostic and Statistical Manual of Mental Disorders V (DSM 5), conversion disorder is also referred to as functional neurologic symptom disorder (FNSD). FNSD/CD is characterized by the presence of at least one neurological deficit that does not have any medical or neurological etiology and is incompatible with any known medical or neurological disorders. Psychological distress or conflict may be manifested as a physical symptom in patients with CD. La belle indifference is not formally included in DSM 5 as a diagnosis. However, it is used in conjunction with CD.[3]

According to the DSM 5, the mere presence of la belle indifference does not confirm the diagnosis of CD. However, la belle indifference is most commonly seen in patients with CD, so this article will focus primarily on its association with CD. For a full review of CD, please refer to the conversion disorder article by StatPearls.[4] 

In the DSM 5, CD is classified under somatic symptom and related disorders (SSD). Other diagnosis included under SSD includes somatic symptom disorder, psychological factors affecting other medical conditions, illness anxiety disorder, and factitious disorder. The most common presentation of FNSD/CD includes weakness or paralysis of one side of the body or bilaterally, abnormal movements (including tremors, myoclonus, dystonic movements, etc.), seizures (psychogenic neuroleptic seizures), swallowing problems (globus), speech problems (dysphonia or aphonia), sensory loss (vision or olfactory issues) and syncopal episodes.


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The etiology of conversion disorder can be multifactorial. A vast majority of patients that present with FNSD/CD have an identifiable stressor. However, the absence of a stressor does not exclude the presence of FNSD/CD. It may be noted that a causal relationship between psychological distress and the occurrence of conversion is difficult to establish.

According to recent functional magnetic resonance imaging (fMRI) studies exploring a brain-based cognitive model for CD, there appears to be a disconnect between the neuronal networks of the anterior cingulate and prefrontal cortex, which points to the psychodynamic dissociation hypothesis.[2][5] These studies also suggest an association between depression, post-traumatic stress disorder (PTSD), and CD.[2] Personality disorders, mood, and anxiety disorders are the most common comorbidities seen in patients with CD.[6] People with maladaptive behaviors and poor coping strategies are at an increased risk of CD.

Psychosocial stressors, including neglect, and physical or sexual abuse, are also implicated in the manifestation of CD. For example, dissociative phenomena and motor symptoms that are common in patients with PTSD are also seen in CD.[7][8][9]

The incidence of CD in general hospital patients is around 5%.[10] The estimated prevalence of psychogenic non-epileptic seizures (PNES) is 33 per 100,000.[11] In another study that followed over 0.35 million individuals for three years, the incidence rate of PNES was 4.9 per 100,000.[12] In a study of the general population in New York, the incidence of CD was 11-22 per 100,000.[13]

CD is more commonly seen in females than in males.[14][15] It is also commonly seen in individuals with low socioeconomic status, lower education, and rural population.[13][16] The onset of FNSD/CD is generally in late adolescence and early adulthood. 47% of individuals have comorbid anxiety or depression.[12] In patients with CD, over two-thirds of patients have a history of depression or trauma.[17][18]

History and Physical

A thorough physical and neurological exam should be conducted to exclude serious medical and neurological disorders. Neurological disorders that need to be ruled out include multiple sclerosis, stroke, Guillain-Barré syndrome, myopathies, polymyositis, and myasthenia gravis. Depending on the presentation, a focused neurological exam should be performed. Described below are some tests for motor symptoms with high sensitivity and specificity for CD. A full range of neurological exams for motor, sensory, and gait are summarized by Oneal and Baslet.[19]

Hoover's sign (63% Sensitivity & 100% specificity): This test is commonly used to separate organic from the nonorganic cause of weakness or paralysis. An examiner's hand is placed below the heel of the affected leg, and the patient is asked to flex the hip of the normal leg against resistance. In organic disorders, there should not be any pressure on the examiner's hand on the affected side, while pressure is felt in patients with FNSD/CD.[20]

Variable Strength (63% sensitivity and 97% specificity): The weakness is inconsistent with variable force at different locations.

Inconsistencies in the exam (13% sensitivity and 98% specificity): Individuals have an inconsistent presentation of signs and symptoms when performing voluntary activity and when they are being examined. 

Co-contraction (17% sensitivity and 100% specificity): When asked to flex the elbow, there is a contraction of both the triceps and biceps.[21]

For tremors, distraction affecting the tremor (92% sensitivity and 94% specificity), tremor variability (22% sensitivity and 92% specificity), and tremor entertainment ( (91% sensitivity and 92% specificity) are commonly used.[22]


EEG and video-EEG should be ordered to rule out epileptic seizures. MRI is essential to rule out neurological disorders like multiple sclerosis or stroke. Labwork should be done to rule out Guillain-Barré syndrome, myopathies, polymyositis, and myasthenia gravis. Some patients with PNES may also have epileptogenic seizures [23]. The approximate incidence of epileptic seizures in patients with PNES is 10% [24]. In some cultures, seizure-like episodes are common during cultural rituals. Therefore, providers must carefully explore the religious and cultural association with symptoms in these individuals.

Treatment / Management

Treatment of FNSD/CD poses a significant challenge due to the lack of empirical studies and RCTs.[16] A comprehensive treatment approach involving multiple specialties - primary care providers (PCPs), psychiatrists, neurologists, and psychologists is usually needed. The three P's approach -identifying predisposing factors, precipitating stressors, and perpetuating factors is suggested in the literature.[25]

Cognitive-behavioral therapy (CBT) is identified as an effective treatment for SSD.[26][27] In a pilot study of 16 PNES patients treated with CBT, a significant reduction of symptoms was seen at a 6-month follow-up.[28] In a study looking at the effectiveness of pharmacology, 7 out of 10 patients with conversion disorder showed improvement in motor symptoms with antidepressants.[29] Though there are several treatment strategies suggested, there is no effective evidence-based treatment for FNSD/CD.[27] Providers should focus on the effective treatment of comorbidities and the management of stressors and psychological trauma.

Differential Diagnosis

FNSD/CD can be present in patients with physical illness. Patients with epileptogenic seizures may also have concurrent PNES.[23] Patients with significant and life-threatening physical illnesses may also present with dissociative symptoms and conversion. However, patients with la belle indifference do not appear to be distressed by their symptoms. FNSD/CD is frequently seen in patients with multiple psychiatric comorbidities like depression, anxiety, PTSD, and personality disorders. Multiple sclerosis, stroke, Guillain-Barré syndrome, myopathies, polymyositis, and myasthenia gravis should be considered in the differential.


The prognosis of FNSD/CD depends on the onset and duration of the symptoms. Acute onset and short duration with an identifiable stressor generally have a good prognosis. For a quarter of patients, the symptoms of conversion resolve within weeks.[16] In a longitudinal study of patients with psychogenic movement disorders, patients with psychiatric comorbidities have prolonged duration of symptoms.[30]


According to a systematic review by Stone et al., there is only a 4% chance of misdiagnosis of FNSD/CD.[31] However, there remains a risk that a true neurological or medical etiology may be missed, and treatment is delayed in these cases. Hence an immediate referral by PCP for comprehensive screening and assessment by psychiatry and neurology is essential to arrive at an accurate diagnosis in a reasonable amount of time.


Primary teams should consult neurology, psychology, and psychiatry for appropriate diagnosis, referral, and treatment of la belle indifference and FNSD/CD.

Deterrence and Patient Education

A multidisciplinary treatment approach is needed to diagnose and treat FNSD/CD. Engaging patients is critical for positive treatment outcomes. The first step towards patient engagement is the patient’s acceptance of their diagnosis. Educating the patient on their physical symptoms and how the diagnosis of FNSD/CD was made should be explained in a manner that the patient understands.[32]

Enhancing Healthcare Team Outcomes

A comprehensive screening and assessment by a multidisciplinary treatment team, including primary care providers, neurology, and psychiatry, are needed for the diagnosis and treatment of FNSD/CD. Active collaboration and agreement regarding the diagnosis across specialties involved in the care of the patient are required to prevent unnecessary consultations, testing, multiple hospital visits, and health care utilization. Patients should be educated on their presenting symptoms, and efforts should be made to engage the patient in treatment. Treatment outcomes are generally worse if the patient does not have buy-in in their diagnosis of FNSD/CD, or do not engage in treatment.[33]



Stone J,Smyth R,Carson A,Warlow C,Sharpe M, La belle indifférence in conversion symptoms and hysteria: systematic review. The British journal of psychiatry : the journal of mental science. 2006 Mar;     [PubMed PMID: 16507959]

Level 1 (high-level) evidence


Ballmaier M,Schmidt R, Conversion disorder revisited. Functional neurology. 2005 Jul-Sep;     [PubMed PMID: 16324233]


Khaddafi MR,Amin MM, A Case Series from Rantauprapat, La Belle Indifference: A Coping Mechanism or Is There Something Organic Behind? Open access Macedonian journal of medical sciences. 2019 Aug 30;     [PubMed PMID: 31777632]

Level 2 (mid-level) evidence


Peeling JL,Muzio MR, Conversion Disorder . 2020 Jan     [PubMed PMID: 31855394]


Hamner MB,Lorberbaum JP,George MS, Potential role of the anterior cingulate cortex in PTSD: review and hypothesis. Depression and anxiety. 1999;     [PubMed PMID: 9989344]


Bourgeois JA,Chang CH,Hilty DM,Servis ME, Clinical Manifestations and Management of Conversion Disorders. Current treatment options in neurology. 2002 Nov;     [PubMed PMID: 12354375]


Hurwitz TA, Somatization and conversion disorder. Canadian journal of psychiatry. Revue canadienne de psychiatrie. 2004 Mar;     [PubMed PMID: 15101499]


Holmes EA,Brown RJ,Mansell W,Fearon RP,Hunter EC,Frasquilho F,Oakley DA, Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical psychology review. 2005 Jan;     [PubMed PMID: 15596078]

Level 2 (mid-level) evidence


Sar V,Akyüz G,Kundakçi T,Kiziltan E,Dogan O, Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. The American journal of psychiatry. 2004 Dec;     [PubMed PMID: 15569899]


Folks DG,Ford CV,Regan WM, Conversion symptoms in a general hospital. Psychosomatics. 1984 Apr;     [PubMed PMID: 6718664]


Asadi-Pooya AA,Sperling MR, Epidemiology of psychogenic nonepileptic seizures. Epilepsy     [PubMed PMID: 25882323]


Duncan R,Razvi S,Mulhern S, Newly presenting psychogenic nonepileptic seizures: incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy     [PubMed PMID: 21195031]


Stefánsson JG,Messina JA,Meyerowitz S, Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta psychiatrica Scandinavica. 1976 Feb;     [PubMed PMID: 1251758]

Level 2 (mid-level) evidence


Bodde NM,Brooks JL,Baker GA,Boon PA,Hendriksen JG,Aldenkamp AP, Psychogenic non-epileptic seizures--diagnostic issues: a critical review. Clinical neurology and neurosurgery. 2009 Jan;     [PubMed PMID: 19019531]


Deka K,Chaudhury PK,Bora K,Kalita P, A study of clinical correlates and socio-demographic profile in conversion disorder. Indian journal of psychiatry. 2007 Jul;     [PubMed PMID: 20661388]


Feinstein A, Conversion disorder: advances in our understanding. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2011 May 17;     [PubMed PMID: 21502352]

Level 3 (low-level) evidence


Carson AJ,Ringbauer B,MacKenzie L,Warlow C,Sharpe M, Neurological disease, emotional disorder, and disability: they are related: a study of 300 consecutive new referrals to a neurology outpatient department. Journal of neurology, neurosurgery, and psychiatry. 2000 Feb;     [PubMed PMID: 10644788]


Roelofs K,Pasman J, Stress, childhood trauma, and cognitive functions in functional neurologic disorders. Handbook of clinical neurology. 2016;     [PubMed PMID: 27719835]


O'Neal MA,Baslet G, Treatment for Patients With a Functional Neurological Disorder (Conversion Disorder): An Integrated Approach. The American journal of psychiatry. 2018 Apr 1;     [PubMed PMID: 29606068]


Mehndiratta MM,Kumar M,Nayak R,Garg H,Pandey S, Hoover's sign: Clinical relevance in Neurology. Journal of postgraduate medicine. 2014 Jul-Sep;     [PubMed PMID: 25121372]


Daum C,Hubschmid M,Aybek S, The value of 'positive' clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. Journal of neurology, neurosurgery, and psychiatry. 2014 Feb;     [PubMed PMID: 23467417]

Level 3 (low-level) evidence


van der Stouwe AM,Elting JW,van der Hoeven JH,van Laar T,Leenders KL,Maurits NM,Tijssen MA, How typical are 'typical' tremor characteristics? Sensitivity and specificity of five tremor phenomena. Parkinsonism     [PubMed PMID: 27346607]


Dickinson P,Looper KJ, Psychogenic nonepileptic seizures: a current overview. Epilepsia. 2012 Oct;     [PubMed PMID: 22882112]

Level 3 (low-level) evidence


Duncan R,Oto M, Predictors of antecedent factors in psychogenic nonepileptic attacks: multivariate analysis. Neurology. 2008 Sep 23;     [PubMed PMID: 18809836]


Ford CV,Folks DG, Conversion disorders: an overview. Psychosomatics. 1985 May;     [PubMed PMID: 2581282]

Level 3 (low-level) evidence


Sumathipala A, What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosomatic medicine. 2007 Dec;     [PubMed PMID: 18040100]


Kroenke K, Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosomatic medicine. 2007 Dec;     [PubMed PMID: 18040099]

Level 1 (high-level) evidence


Goldstein LH,Deale AC,Mitchell-O'Malley SJ,Toone BK,Mellers JD, An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: a pilot study. Cognitive and behavioral neurology : official journal of the Society for Behavioral and Cognitive Neurology. 2004 Mar;     [PubMed PMID: 15209224]

Level 3 (low-level) evidence


Voon V,Lang AE, Antidepressant treatment outcomes of psychogenic movement disorder. The Journal of clinical psychiatry. 2005 Dec;     [PubMed PMID: 16401153]


Feinstein A,Stergiopoulos V,Fine J,Lang AE, Psychiatric outcome in patients with a psychogenic movement disorder: a prospective study. Neuropsychiatry, neuropsychology, and behavioral neurology. 2001 Jul-Sep;     [PubMed PMID: 11513100]


Stone J,Smyth R,Carson A,Lewis S,Prescott R,Warlow C,Sharpe M, Systematic review of misdiagnosis of conversion symptoms and     [PubMed PMID: 16223792]

Level 1 (high-level) evidence


Stone J,Edwards M, Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs. Neurology. 2012 Jul 17;     [PubMed PMID: 22764261]


Baslet G,Seshadri A,Bermeo-Ovalle A,Willment K,Myers L, Psychogenic Non-epileptic Seizures: An Updated Primer. Psychosomatics. 2016 Jan-Feb;     [PubMed PMID: 26791511]