Conversion Disorders

Author: Learning in 10

This is a VIP recording on the topic of conversion disorders. The author of these slides is Dr. Tiltren Liang David, a resident of the National Healthcare Group. The following are the learning objectives of this VIP. Firstly, understanding the definition and epidemiology of conversion disorders. Secondly, understanding the clinical presentation of conversion disorders.

And finally, understanding the management principles and prognosis of conversion disorders. This is an outline of this VIP. Firstly, what are conversion disorders? Secondly, epidemiology of conversion disorders. Thirdly, the DSM-IV text revision criteria for conversion disorders.

Next, critical presentations and diagnosis of conversion disorders. Following this, differential diagnosis of conversion disorders. And finally, management of conversion disorders. What is conversion disorder? The DSM-IV text revision classifies conversion disorder as a somatoform disorder, while I ICD-10 classifies conversion disorder as a dissociative disorder. In conversion and dissociative disorders, there is a loss of motor or sensory function which initially appears to have a neurological cost but is later attributed to a psychological cause.

It can be thought of as psychological distress converted into physical symptoms. In DSM-IV text revision, conversion refers to a motor or sensory deficit, while disassociation refers to a disturbance in conscious state. The following are the DSM-IV text revision diagnostic criteria for conversion disorder. Firstly, one or more symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition.

Conversion Disorders

Secondly, 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 stresses. Thirdly, the symptom or deficit is not intentionally produced or feigned as in factitious disorder or malingering. Fourthly, the symptom or deficit cannot, after appropriate investigation, before fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. Next, the symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. Finally, the symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatisation disorder, and is not better accounted for by another mental disorder. The DSM-IV text revision also specifies the type of symptom or deficit. Firstly, we have motor symptom or deficit.

Secondly, we have sensory symptom or deficit. Thirdly, we have seizures or convulsions. And finally, we have mixed presentation. This slide touches on the epidemiology of conversion disorders. There is a 33% lifetime prevalence in mothers. 25% of patients admitted to general medical services had conversion symptoms sometimes in their lives.

Conversion disorder has an annual incidence of 22 per 100,000 people. It is most common in young women who live in rural areas amongst the uneducated and in the lower socio-economic classes. These are some common symptoms which patients with conversion disorder present with. The symptoms can be divided into motor, sensory, and visceral symptoms. Motor symptoms include involuntary movements, tics, biepharospasm, opisthotonus, seizures, abnormal gait, falling, astasia-abasia, paralysis, weakness, and aphonia. Sensory symptoms include anesthesia, blindness, tunnel vision, and deafness.

Visceral symptoms include psychogenic vomiting, pseudocyesis, globus hystericus, swooning or syncope, urinary retention, and diarrhea. It is common for patients with conversion disorder to have preexisting psychopathology, such as depression, anxiety, schizophrenia, and personality disorder, especially histrionic, dependent, and passive-aggressive personality. It may be precipitated by exposure to others with similar symptoms, and these are called "figures of identity." Careful evaluation is imperative to exclude organic illnesses before the diagnosis of conversion disorder can be made.

And in such, negative evidence and positive evidence is necessary. Of note, 4% of patients have been misdiagnosed of conversion disorder. These are some differential diagnoses of conversion disorder. Firstly, organic conditions, such as medical or neurological illness. Secondly, somatisation disorder, which is characterized by multiple, recurrent, and frequently changing physical symptoms over a lengthy period. And preoccupation with these symptoms lead to marked distress in the patient.

Thirdly, hypochondriasis, in which patients have a preoccupation of having serious physical illness despite evidence to the contrary. Fourthly, fictitious disorder or Munchausen syndrome, in which there is intentional feigning of symptoms with an unclear motivation. And finally, malingering, which is intentional feigning of symptoms with clear motivation. How do we manage conversion disorders? Firstly, it's important to psychoeducate the patient that sensory motor disturbances can result from a loss of conscious control over the affected function. It's also important to provide supportive optimism and suggestion that the symptoms will gradually improve.

Of note, confrontation is seldom helpful. Evidence has shown that cognitive behavioral therapy is useful in the treatment of conversion disorders, while physiotherapy is important in the management of patients with motor symptoms. Finally, pharmacotherapy should be provided for any underlying psychiatric disorder. What is the prognosis of conversion disorders? Studies have shown a complete remission rate of 50% percent by discharge in the general hospital setting. However, 20% to 25% of patients develop recurrent conversion symptoms within one year.

Unilateral functional weakness or sensory disturbances in hospitalized neurological patients persisted in more than 80%. Patients with one conversion symptom may also develop other forms of somatisation or may eventually meet the criteria for somatisation disorder. Finally, to summarize, conversion disorder is a condition in which there is a loss or disturbance of normal motor or sensory function which initially appears to have a neurological or physical cause, but is later attributed to a psychological cause. It is important to exclude organic causes for symptoms to avoid misdiagnosis. It's also important to exclude underlying psychiatric illnesses.

Finally, the mainstay of treatment for conversion disorders is psychoeducation, supportive optimism, and suggestion that symptoms will improve. This is a slide of the key references and acknowledgements for VIP. Thank you.

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