Conversion disorder and somatic symptom disorder are both categorised as somatic symptom and related disorders (previously termed somatoform disorders).
Somatic symptom and related disorders are psychiatric conditions where patients experience distressing physical symptoms associated with abnormal thoughts, feelings, and behaviours in response to these symptoms. They may result from psychological stress that is unconsciously (without awareness) expressed somatically, though the underlying cause is not fully understood.
Risk factors include being female, having a history of abuse or adverse childhood events, and having personality traits of alexithymia (difficulty expressing emotions) or neuroticism. Symptoms that persist with an external focus of control, and without awareness of the psychological and stress-related interplay, can lead to considerable functional impairment and distress.
Diagnosis is made by clinical interview, behavioural observation, physical examination suggestive of pseudoneurological causes, and tests to rule out medical or neurological causes. The diagnosis should not be made solely on the basis of medically unexplained symptoms; rather, it should be based on evidence from the clinical examination and the patient’s abnormal thoughts, feelings, and behaviours in response to the medically unexplained symptoms.
Good doctor-patient relationships and validation of the patient's suffering are essential for effective management. Treatment includes cognitive behavioural therapy, physical therapy, and avoiding unnecessary medicines, tests, and procedures. Diagnosis and treatment of associated comorbid psychiatric conditions benefit overall functioning and recovery.
Long-term management involves interrupting perpetuating factors, maintaining the same doctor, and providing strategies for self-efficacy, distress tolerance, coping, and modulating the interaction of anxiety, stress, and physical symptoms.
Conversion disorder and somatic symptom disorder are psychiatric conditions that fall under the somatic symptom and related disorders category of the DSM-5 (previously termed somatoform disorders). Somatic symptom and related disorders are those with prominent physical symptoms associated with significant distress and impairment of function.
Conversion disorder is characterised by voluntary motor or sensory function deficits that suggest neurological or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterised by one or more somatic symptoms that are distressing or result in significant disruption of daily life. To meet DSM-5 criteria, these patients must have excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms; persistently high levels of anxiety about health or symptoms; excessive time or energy devoted to these symptoms or health concerns. Importantly, even if any one somatic symptom is not continuously present, the state of being symptomatic is persistent (typically more than 6 months).
History and exam
Key diagnostic factors
- unconventional behaviour during history
- emotional processing problems
- recent life stressors
- remote life stressors
- multiple illness behaviours
- unusual neurological deficits
- give-way weakness
- inconsistent examination findings
- false sensory findings
- distractible symptoms
- inconsistent paralysis
- generalised seizure-like motor movements without loss of awareness
- bizarre movements
- gait disorders
- functional (psychogenic) movement disorders
Other diagnostic factors
- cognitive complaints
- Hoover's sign
- speech disturbance
- swallowing disturbance
- convergence spasm
- history of sexual or physical abuse
- history of unstable childhood
- history of trauma-related disorders
- female sex
- previously poor doctor-patient relationships
1st investigations to order
- laboratory testing
Investigations to consider
- comprehensive neuropsychological testing
- standardised personality testing
- focused symptom inventories
somatic symptom disorder
- Bipolar disorder
- Schizoaffective disorder
- Panic disorder
- Clinical practice guidelines for the management of somatoform disorders in children and adolescents
- Management of patients with physical and psychological problems in primary care: a practical guide
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