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SOMATOFORM AND CONVERSION DISORDERS
Walid Michel NASSIF MD
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DEFINITION (DSM IV) Somatoform Disorders: : Group of disorders characterized by physical symptoms suggesting medical disease, with associated excessive thoughts, feelings and illness behaviors [without (sufficient) organic pathology or known pathophysiological mechanism]
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DIFFERENTIAL _ + + + +/- -/+ - + -/+ - -/+ -/+ MALINGERING VOLUNTARY
CONTROL UNCONSCIOUS GAIN CONSCIOUS GAIN _ + + MALINGERING FACTITIOUS + +/- -/+ INCL. MUNCHAUSEN - + -/+ SOMATOFORM - -/+ -/+ GENUINE ILLNESS
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S0MATOFORM DISORDERS/SOMATIC SYMPTOM DISORDER (DSM IV/V)
Somatization disorder (Somatic Symptom Disorder) Hypochondriasis (Illness Anxiety Disorder) Somatoform pain disorder (Pain Disorder, SSD with predominant pain) Conversion disorder (Functional Neurologic SD) Body dysmorphic disorder (OCD spectrum) Psychological Factors Affecting other (known) Medical Conditions Undifferentiated SD (other SSD) SD NOS (unspecified SSD)
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CONVERSION DISORDER Loss of, or alteration in physical functioning suggesting a physical disorder Most commonly pseudoneurological DSM IV: Typically preceded by conflicts or stressors, and not intentionally produced
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EPIDEMIOLOGY Frequent Female preponderance Onset teens to young adults
? Lower socioeconomic groups
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PHENOMENOLOGY “Traditional”: Mutism, deafness, blindness, syncope, seizures, amnesia, paralysis, anesthesia… Subtle, sophisticated, more diagnostically challenging presentations Plasticity of symptoms Symbolism vs identification and imitation
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COMORBIDITY Neurologic Psychiatric: Psychosis Depression
Personality Disorders Other somatoform symptoms
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WORK-UP Medical and neurologic history
Correlation with conscious/unconscious emotions Primary and secondary gain Psychiatric profile/family assessment
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WORK-UP (CONT.) History of abuse Presence of a model
Other unexplained medical symptoms
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PRESENTING THE DIAGNOSIS
Team approach Insistence on unconscious nature of symptoms Highlighting positives "Normalization" Assurance of ongoing medical treatment Reinforcing the necessity and benefit of psychiatric treatment (individual and family)
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CONFUSING ELEMENTS History of documented organic pathology
Present organic findings Absence of overt psychopathology Absence of previous somatization Absence of “la belle indifference” Sex/Age
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AVOID! “It’s stress” (if chronic) “It’s depression”
Indiscriminate use of antidepressants Assuming conversion disorder is always benign
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TREATMENT Spontaneous remission Support, reassurance, suggestion
Invasive diagnostic/therapeutic procedures only for objective evidence of disease Hypnosis, placebo procedures Resolution of underlying conflict Individual, family psychological intervention Physical, psychiatric rehabilitation
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