1. SOMATOFORM AND CONVERSION DISORDERS
Walid Michel NASSIF MD

2. 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]

3. DIFFERENTIAL _ + + + +/- -/+ - + -/+ - -/+ -/+ MALINGERING VOLUNTARY
CONTROL
UNCONSCIOUS
GAIN
CONSCIOUS
GAIN _ + +
MALINGERING
FACTITIOUS +
+/-
-/+
INCL. MUNCHAUSEN - +
-/+
SOMATOFORM -
-/+
-/+
GENUINE ILLNESS

4. 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)

5. 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

6. EPIDEMIOLOGY Frequent Female preponderance Onset teens to young adults
? Lower socioeconomic groups

7. PHENOMENOLOGY
“Traditional”: Mutism, deafness, blindness, syncope, seizures, amnesia, paralysis, anesthesia…
Subtle, sophisticated, more diagnostically challenging presentations
Plasticity of symptoms
Symbolism vs identification and imitation

8. COMORBIDITY Neurologic Psychiatric: Psychosis Depression
Personality Disorders
Other somatoform symptoms

9. WORK-UP Medical and neurologic history
Correlation with conscious/unconscious emotions
Primary and secondary gain
Psychiatric profile/family assessment

10. WORK-UP (CONT.) History of abuse Presence of a model
Other unexplained medical symptoms

11. 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)

12. 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

13. AVOID! “It’s stress” (if chronic) “It’s depression”
Indiscriminate use of antidepressants
Assuming conversion disorder is always benign

14. 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