4Somatoform DisordersDefinition…taking the form of soma (w/ implication of nonsomatic)…”unexplained disorders”A broad group of illnesses with bodily signs and symptoms as the predominant focus, influenced by the psycheConcept of mind/body interactions, with signals from the brain (?mechanism) indicating a problemNot based on theoretical construct or laboratory findings-no significant substantiating data, yet vigorous and sincere complaints “not imaginary”
5Conversion Disorder Definition An illness of symptoms or deficits affecting voluntary motor or sensory functions, suggesting another medical condition, but judged due to psychological factors because of preceding conflicts or other stressors.Symptoms or deficits are not intentionally produced, not due to substance, and not limited to pain or sexual symptomatology.Gain is primarily psychological, and not social or monetary or legal.
6Conversion Disorder Definition A disturbance of bodily function not conformingto current concepts of neurological anatomy and physiology:Characterized by the presence of one or more neurological symptoms, unexplained by a known neurological or medical disorder;Typically occurring in a setting of stress, and producing considerable dysfunction;Requiring for diagnosis the association of psychological factors, present at the initiation or exacerbation of symptoms.
7Conversion Disorder History A disorder stemming from early concepts of hysteria:Sigmund Freud introduced the term conversion (based on his work with Anna O); andHypothesized that the symptoms of conversion reflect unconscious conflict.
8Conversion Disorder Comparative Nosology DSM-IV-TR conversion d/o=dissociative d/o in ICD-10Comorbid dissociative d/o in approximately 30% of inpatients with DSM-IV-TR conversion disorder
9Conversion Disorder Epidemiology Some symptoms, but not severe enough to warrant diagnosis in 1/3 of general population at some timeLifetime risk by some studies of 33% for either transient or longer-term disorder25-30% of admissions to VA hospitalsRange in general population of /100,000DSM-IV-TR range of 1-500/100,000
10Conversion Disorder Epidemiology Estimate of 20-25% admitted to a general medical service with conversion symptoms at some time during lifeEngel GL. Conversion symptoms. In: MacBryde CM, ed. 5th ed. Signs and symptoms: applied pathologic physiology and clinical interpretation. Philadelphia: JB Lippincott, 1970:5-16% on several psychiatric consultation services referred for assistance in diagnosis and management of conversion symptomsLazare A. Hysteria. In: Hackett TP, Cassem NH eds. MGH handbook of general hospital psychiatry. St Louis: CV Mosby, 1978:24% in 500 psychiatric outpatients with at least one conversion symptomGuze SB, Woodruff RA, Clayton PJ. Am J Psychiatry. 1971;128:643-6.
11Conversion Disorder Epidemiology Ratio of women to menRange of 2/1 to 10/1 in adultsIncreased female predominance in childrenSymptoms in women more common on left side of bodyWomen with conversion symptoms more likely to subsequently develop somatization disorderAssociation in men between conversion disorder and antisocial personality disorderMen with conversion disorder often involved in occupation or military accidents
12Conversion Disorder Epidemiology Onset at any age, but most common in late childhood to early adulthood (rare before 10 years of age, or after 35, but reported as late as the ninth decade of life)Probability of occult neurological or other medical condition high with onset of symptoms in middle orold age.
13Conversion Disorder Epidemiology Common PrototypesRural populationsDeveloping nations and regionsPersons with limited education and medical knowledge,or decreased IQLower socioeconomic groupsMilitary personnel exposed to combatIncreased FrequencyRelatives of probands with conversion disorderMonozygotic, but not dizygotic, twin pairs
14Conversion Disorder Epidemiology Cultural norms are important considerationsThe form of conversion may reflect cultural ideas about acceptable ways to express distress (e.g. falling, or an alteration of consciousness)Behaviors resembling conversion or dissociative symptoms are aspects of certain culturally sanctioned religious and healing ceremonies
15Conversion Disorder Comorbidity Common Axis I psychiatric conditions:Depressive disorders (increased suicide risk)Anxiety disordersSomatization disordersConversion in schizophrenia reported but considered uncommon, yet ¼ to ½ admissions to a psychiatric unit for conversion disorder have significant mood disorder or schizophreniaPersonality Disorders5 to 21% histrionic9 to 40% passive-aggressive/dependentAntisocialMedical and especially neurological disorders occur frequently, with elaboration of symptoms stemming from original organic lesion
17Conversion Disorder Etiology Psychoanalytic FactorsRepression of unconscious intrapsychic conflict (instinctual impulse, e.g. aggression/sexuality, and prohibitions of expression)Conversion of anxiety into a physical symptom-”the symptom binds anxiety”Symptoms allow partial although disguised expression of the forbidden wish or urge, such as to avoid conscious confrontation with the unacceptable impulsesThe conversion disorder symptom has symbolic relation to the unconscious conflict (e.g. vaginismus with sexual desire, syncope with arousal, paralysis with anger)Symptoms communicate need for special consideration/treatmentThe individual may derive secondary gain, with symptoms serving as a nonverbal means of controlling or manipulating others
18Conversion Disorder Etiology Learning TheoryConversion disorder considered as piece of classically conditioned learned behaviorSymptoms of illness, learned in childhood, are called forth as a means of coping with an otherwise impossible situation.
19Conversion Disorder Etiology Biological FactorsBrain imagingHypometabolism of dominant hemisphereHypermetabolism of nondominant hemisphere? Impaired hemispheric communicationCorticofugal feedback? Excessive cortical arousal setting off negative feedback loops between the cortex and reticular formation w/ inhibitionNeuropsychological testsSubtle cerebral impairments in verbal communication, memory, vigilance, affective incongruity, and attentionIncreased incidence with head trauma/organicity
20Conversion Disorder Diagnosis DSM-IV-TR limits to those symptoms that affect a voluntary motor or sensory function (i.e. neurological symptoms)
21Conversion Disorder DSM-IV-TR Criteria One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressorsThe symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience
22Conversion Disorder DSM-IV-TR Criteria The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.Specify type of symptom or deficit:with motor symptom or deficitwith sensory symptom or deficitwith seizures or convulsionswith mixed presentation
23Conversion Disorder Clinical Features Most common symptomsParalysisBlindnessMutism
24Conversion Disorder Clinical Features Sensory symptomsAnesthesia and paresthesia common, especially in extremities (although all sensory modalities can be involved)Distribution of the neurological deficit inconsistent with either central or peripheral neurological disease (e.g. stocking-and-glove anesthesia, and hemianesthesia beginning precisely along the midline)Possible involvement of organs of special sense (deafness, blindness, tunnel vision)Unilateral or bilateralIntact sensory pathways by neurological exam(e.g. conversion disorder blindness: ability to walk around without collision or self-injury, with pupils reactive to light, and normal cortical evoked potentials.)
25Conversion Disorder Clinical Features Motor symptomsAbnormal movements (gait disturbance, weakness/paralysis)Movements generally worsen with calling of attentionPossible gross rhythmical tremors, chorea, tics, and jerksAstasia-abasia (wildly ataxic/staggering gait, gross irregular/jerky truncal movements, thrashing/waving of arms-rare falls w/o injury)Paralysis/paresis involving one, two, or all four limbs (w/o conformation to neural pathways)Reflexes remain normalNo fasciculations/muscle atrophy (except chronic conversion)Normal electromyography
26Conversion Disorder Clinical Features Seizure symptomsPseudoseizuresDifferentiation from true seizure difficult by clinical observation alone1/3 of those with pseudoseizures have coexisting epileptic disorderTongue biting, urinary incontinance, and injuries after falling can occur (although generally absent)Pupillary and gag reflexes retainedNo postseizure increase in prolactin concentration
27Conversion Disorder Clinical Features Associated psychological symptomsPrimary gainSecondary gainLa belle indifferenceIdentification
28Conversion Disorder Clinical Features Associated psychological symptomsPrimary gainInternal conflicts remain outside awarenessSecondary gainTangible advantages and benefits as a result of being sick (excuses from obligations and difficult situations, support and assistance otherwise not forthcoming, control of behavior of others)
29Conversion Disorder Clinical Features Associated psychological symptomsLa belle indifferenceInappropriate cavalier attitude toward serious symptoms (lacking in some, but also in other seriously ill medical patients with stoic attitude-inaccurate determinant of conversion disorder)IdentificationUnconscious modeling of symptoms after someone considered important to the patientWith pathological grief reaction, bereaved persons commonly have symptoms of the deceased
30Conversion Disorder Clinical Features No specific standard laboratory testsAbsence of tests supports diagnosisExperimental psychophysiologyUnique sympathetic nervous system response as measured by skin conductance upon anxiogenic stimulusMore rapid cortical evoked potential spikes in contralateral sensory cortex upon physical stimuli
31Conversion Disorder Differential Disorder The most important conditions in the differential diagnosis are neurological or other medical disorders and substance-induced disorders.
32Conversion Disorder Differential Diagnosis Concomitant or previous neurological disorder or a systemic disease affecting the brain reported in 18% to 64% of cases of conversion disorder25% to 50% of cases classified as conversion disorder eventually receive diagnoses of neurological or nonpsychiatric medical disorders
33Conversion Disorders Differential Diagnosis 7-11 year follow up of 99 patients: 22 (30%) of 73 available subjects had organic illness accounting for presenting symptoms initially diagnosed as conversion (Slater ETO, Glithero E J. Psychosom Res, 1965;9:9-13).year follow up of 24 patients discharged form the neuroscience services of a teahing hospital with diagnosis of conversion:5 (21%) of 24 with diagnosable neurological disease (Gatfield PD, Guze SB. Dis Nerv Syst, 1962;23:623-31).6-12 month follow up of 50 patients discharged from the neurology service of a teaching hospital with conversion in differential diagnosis: 7 (14%) found with organic illness and 3 (6%) with hysterical elaboration of organic pathology (Raskin M, Talbott JA, Meyerson AT. JAMA, 1966;197:530-4).64 patientswith diagnosis of conversion by psychiatric consultation service followed for an average of 3.3 years: 8 (13%) with organic illness (Stefansson JG, Messina JA, Meyerowitz S. Acta Psychiatr Scand, 1976;53:119-38).
34Conversion Disorder Differential Diagnosis Symptoms probably the result of conversion disorder if resolved by suggestion, hypnosis, or parenteral amobarbital or lorazepam.
36Conversion Disorder Differential Diagnosis Psychiatric disordersSchizophreniaHallucinations presenting with conversion disorder generally present w/o other psychotic symptoms and often involve more than one sensory modality w/ vague or fantastic content.Depressive disordersAnxiety disordersConsider high anxiety states with phobia and panic attack associated with somatic complaints (e.g. difficulty swallowing)Dissociative disordersDual diagnosis possible
37Conversion Disorder Differential Diagnosis Somatization disorderIncludes possible sensorimotor symptoms, but chronic coarse beginning early in life involving many other organ systemsHypochondriasisNo actual loss or distortion of functionChronic somatic complaints, not limited to neurological symptoms, with characteristic attitudes and beliefs (disease phobia)Body dysmorphic disorderImagined or slight defect in appearance, with no voluntary motor or sensory dysfunctionPain disorder-symptoms limited to pain (solely psychological)Sexual dysfunction-symptoms limited to sex
38Conversion Disorder Differential Diagnosis Malingering and factitious disorderSymptoms under conscious, voluntary controlHistory with malingering usually more inconsistent and contradictory than with conversion disorderFraudulent behavior clearly goal directed with malingering
39Conversion Disorder Distinctive Physical Findings CONDITIONTESTTunnel visionVisual fieldsProfound monocular blindnessSwinging flashlight sign(Marcus Gunn)Binocular visual fieldsSevere bilateral blindness“Wiggle your fingers;I’m just testing coordination.”Sudden flash of bright light“Look at your hand.”“Touch your index fingers.”
40Conversion Disorder Distinctive Physical Findings CONDITIONTESTAphoniaRequest a coughIntractable sneezingObserve
42Conversion Disorder Distinctive Physical Findings CONDITIONTESTAnesthesiaMap dermatomesHemianesthesiaCheck midlineAstasia-abasiaWalking, dancingParalysis, paresisHand drop onto faceHoover testCheck of motor strength
43Conversion Disorder Course and Prognosis Initial symptoms resolve within a few days to < a monthin 90 to 100% (95% remit spontaneously, usually by 2 weeks)75% have no further episodes, with 20-25% recurring within a year during periods of stress25 to 50% present later with neurological disorders or nonpsychiatric medical conditions affecting the nervous system
44Conversion Disorder Course and Prognosis Predictors of good prognosisSudden onsetEasily identifiable stressorGood premorbid adjustmentNo comorbid psychiatric or medical disordersNo ongoing litigationShort durationShort interval between onset and initiation of treatmentAbove average intelligenceParalysis, aphonia, blindness (tremor and seizures-poor prognosis)
45Conversion Disorder Management/Treatment Acute casesReassurance/appropriate rehabilitationResolution usually spontaneousPsychotherapyA relative contraindication
46Conversion Disorder Treatment Chronic casesAggressive therapy of comorbid psychiatric illnessDouble bind approach to therapyPharmacotherapyAnxiolytic or antidepressant medications ?Amobarbital interview?Psychotherapy?
47Conversion Disorder Management/Treatment PsychotherapyInsight-oriented supportive or behavior therapyRelationship with a caring and confident therapist most important feature of the therapyConfrontation re symptoms being imaginary detrimentalSuggestion of focus on stress and coping sometimes helpful for those resistant to idea of psychotherapyPsychodynamic approachesExploring intrrapsychic conflicts, and the symbolism of conversion symptoms ???