Conversion disorder and somatic symptom disorder are both categorized 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 behaviors 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, behavioral observation, physical exam suggestive of pseudoneurologic causes, and tests to rule out medical or neurologic 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 exam and the patient’s abnormal thoughts, feelings, and behaviors 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 behavioral 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-TR (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 characterized by voluntary motor or sensory function deficits that suggest neurologic or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterized by one or more somatic symptoms that are distressing or result in significant disruption of daily life. To meet DSM-5-TR criteria, these patients must have excessive thoughts, feelings, or behaviors 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 behavior during history
- emotional processing problems
- recent life stressors
- remote life stressors
- multiple illness behaviors
- unusual neurologic deficits
- give-way weakness
- inconsistent examination findings
- false sensory findings
- distractible symptoms
- inconsistent paralysis
- generalized seizure-like motor movements without loss of awareness
- bizarre movements
- gait disorders
- functional (psychogenic) movement disorders
Other diagnostic factors
- cognitive complaints
- Hoover 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
- standardized 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
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