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SOMATOFORM AND CONVERSION DISORDERS

This article explores somatoform and conversion disorders, which are characterized by physical symptoms without underlying organic pathology. It provides an overview of different types of disorders, their epidemiology, phenomenology, comorbidity, and diagnostic work-up. The article also discusses the importance of a team approach and the confusing elements that may arise during diagnosis. Treatment options, including support, reassurance, psychological interventions, and rehabilitation, are also discussed.

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SOMATOFORM AND CONVERSION DISORDERS

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  1. SOMATOFORM AND CONVERSION DISORDERS Walid Michel NASSIF MD

  2. 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]

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

  4. 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) S0MATOFORM DISORDERS/SOMATIC SYMPTOM DISORDER (DSM IV/V)

  5. 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

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

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

  8. COMORBIDITY • Neurologic • Psychiatric: Psychosis Depression Personality Disorders Other somatoform symptoms

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

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

  11. PRESENTING THEDIAGNOSIS • 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)

  12. 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

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

  14. 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

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