Conversion Disorder (The Modern Hysteria)* Yusuf Kaaki * BJPsych

Objectives To know what is conversion disorder. To know the manifestation. To know DSM 5 diagnostic criteria. To know how to approach a patient with conversion disorder. To know the diffreantial diagnosis. To know how to Treat.

Conversion Disorder Conversion disorder is characterized by neurologic symptoms (eg, weakness, abnormal movements, or nonepileptic seizures) that are inconsistent with a neurologic disease, but cause distress and/or impairment. * UpToDate

Epidemiology The estimated prevalence of conversion disorder in community studies include Younger age, Female sex, Greater disability (physical, role, and social functioning). Onset of conversion disorder rarely occurs prior to age 10 years. * UpToDate

But why? Reduction of inner stress and tension. The advantage that the patient gains. * Basic psychiatry

Manifestations Nonepileptic seizures * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement Speech disturbances * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement Speech disturbances Globus sensation (swallowing symptoms) * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement Speech disturbances Globus sensation (swallowing symptoms) Sensory symptoms * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement Speech disturbances Globus sensation (swallowing symptoms) Sensory symptoms Visual symptoms * UpToDate

Manifestations Nonepileptic seizures Weakness and paralysis Abnormal movement Speech disturbances Globus sensation (swallowing symptoms) Sensory symptoms Visual symptoms Cognitive symptoms * UpToDate

How? Psychodynamic Explanation: Unconscious intrapsychic conflict between an instinctual impulse and the prohibition against its expression is repressed. Physical expression alos help the patient to manipulate and control others indirectly. * Basic psychiatry

How? Neurobiological Explanation: Excessive cortical arousal sets off negative feedback loops between cerebral cortex & the brainstem reticular formation. * Basic psychiatry

DSM-5 Diagnosis of conversion disorder requires each of the following criteria: One or more symptoms of altered voluntary motor or sensory function. * UpToDate

DSM-5 Diagnosis of conversion disorder requires each of the following criteria: Clinical findings that demonstrate incompatibility between the symptom and recognized neurologic or general medical conditions. * UpToDate

DSM-5 Diagnosis of conversion disorder requires each of the following criteria: The symptom or deficit is not better explained by another medical or mental disorder. * UpToDate

DSM-5 Diagnosis of conversion disorder requires each of the following criteria: The symptom or deficit causes significant distress, psychosocial impairment, or warrants medical evaluation. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Seizures or attacks – (psychogenic nonepileptic seizures) abnormal generalized limb shaking and apparent impaired or loss of consciousness resembling epileptic attacks or fainting (syncope). * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Weakness or paralysis. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Abnormal movement – Includes dystonic movement, gait disorder, myoclonus, and tremor. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Anesthesia or sensory loss – Includes symptoms such as loss of touch or pain sensation. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Special sensory symptom – Includes visual (eg, double vision, blindness, or tubular visual field [tunnel vision]), hearing (eg, deafness), or olfactory disturbance. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Swallowing symptom – This symptom is also called globus sensation or globus pharyngeus and is characterized by the sensation of a lump in the throat. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Speech symptom – Includes dysphonia and slurred speech. * UpToDate

DSM-5 subtypes They are based upon the presenting symptom or deficit: Mixed symptoms – Two or three different subtypes of symptoms are present (eg, paralysis plus blindness). * UpToDate

ICD-10 International Classification of Diseases - 10th Revision (ICD-10) — are often not used because many patients with the disorder do not fulfill all of the criteria. * UpToDate

DIFFERENTIAL DIAGNOSIS Neurologic and general medical disorders (eg, multiple sclerosis, myasthenia gravis, movement disorders, stroke, spinal disorders, and epilepsy) Psychiatric disorders (eg, somatic symptom disorder, factitious disorder) Malingering * UpToDate

Management Investigations: Medical history Physical examination Laboratory tests Mental status examination Clinicians taking the initial history of patients with a possible diagnosis of conversion disorder should ask about all current somatic symptoms, circumstances at onset, dissociation, disability, illness beliefs, psychosocial functioning, family history, course of illness, previous conversion symptoms, prior hospitalization, prior clinicians, recent psychological stressors, and comorbid psychiatric symptoms and disorders. Questions about physical and sexual abuse are often best deferred until trust has been established during the preceding phases of the assessment. * UpToDate

Management Laboratory and radiologic studies — required to seek neurologic/general medical disorders that either explain the presenting symptoms or are comorbid. * UpToDate

Management Treatment: Education about the diagnosis as first line treatment rather than other therapies. Sympathetic approach with reassrance that the condition is a response to stress. Avoid confrontation. * UpToDate / Basic psychiatry

Management Treatment: For patients with conversion disorder who do not respond to education, CBT & physical therapy as second line treatment rather than other therapies. * UpToDate

Management Treatment: Pharmacotherapy as third line treatment (eg. Antidepressants as paroxetine or citalopram/ diazepam). Antidepressants are typically indicated for treating comorbid anxiety and depressive disorders. * UpToDate / Basic psychiatry

Management Treatment: conservative approach in primary care clinic that avoids excessive investigations and treatments, and includes regular visits to monitor for general medical and psychiatric illnesses. * UpToDate

Summary Prognosis is good if it’s acute and earyl of age. Among young females. Symptoms mimic other diseases on neurological origins. In diagnosting the disorder, pay close attention to not miss a medical disease. Multiappraoch to treat the patient.

Thank You..