SOMATOFORM AND CONVERSION DISORDERS Walid Michel NASSIF MD

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]

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

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)

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

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

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

COMORBIDITY Neurologic Psychiatric: Psychosis Depression Personality Disorders Other somatoform symptoms

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

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

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)

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

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

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