somatoform disorder conversion

8/12/2019 Somatoform Disorder Conversion

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eMedicine Specialties > Pediatrics: Developmental and Behavioral >

Medical Topics

Somatoform Disorder: ConversionNeelkamal S Soares, MD, FAAP,Assistant Professor, Department of Pediatrics,University of Kentucky; Consulting Staff, Department of Pediatrics, Kentucky ClinicLinda Grossman, MD,Associate Professor, Division Head, Department of Pediatrics,Division of e!avioral and Developmental Pediatrics, University of "aryland Sc!ool of"edicine

Updated# $ov %&, %''(

Introduction

Conversion disorder is part of t!e group of somatoform disorders t!at )ere first delineated as a class

of psyc!iatric disorders in *+&' in t!e American Psyc!iatric Associations -APA Diagnostic and

Statistical Manual of Mental Disorders (DSM), 3rd edition-DSM-III.*

Somatoform disorders are c!aracteri/ed 0y persistent p!ysical symptoms )it!out a demonstra0le

organic pat!ology or p!ysiologic e1planation along )it! clinical indications t!at symptoms are linked to

psyc!ological factors or conflicts.

Diagnostic criteria for t!e somatoform disorders )ere esta0lis!ed for adults, and t!e same criteria, in

general, are applied to c!ildren. Diagnosing somatoform disorders in c!ildren and adolescents is often

more difficult 0ecause t!e e1pression of emotional distress in t!e form of p!ysical complaints is

developmentally appropriate in younger c!ildren. Ho)ever, )!en p!ysical symptoms are persistent

and a c!ilds functioning deteriorates, consideration of a somatoform disorder is indicated.

Background And Nomenclature

Historical models of conversion

2!e ancient 3gyptians attri0uted somatoform disorders to a 4)andering uterus.4 5ene Descartes *(t!6

century paradigm of separation 0et)een t!e psyc!e and t!e soma guided t!e development of

reductionist medical model )it! a dualist outlook influencing management of conversion symptoms.
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2!e *&t!6century t!eories of disease included !umoral t!eory -ie, disease is result of im0alance of

!umors and temperament and master6organ t!eories -ie, t!e 0rain influenced 0y t!e master organs

consisting of t!e uterus, digestive system, or nerves.

7n t!e *+t! century, refle1 t!eory asserted t!at every organ can influence every ot!er organ,

independent of t!e mind and )ill. C!arcot conceptuali/ed !ysteria as an in!erited C$S disease

caused 0y functional lesions in t!e nervous system t!at could not 0e locali/ed. y t!e end of t!e *+t!

century, t!e concept of dissociation )as referred to as psyc!ological automatisms and emp!asi/ed t!e

coe1istence of separate mental systems t!at )ould normally 0e integrated into persons

consciousness, identity, and p!ysical self. 2!is concept is recently reemerging as somatoform

dissociation and neodissociation t!eory.

7n t!e %'t! century, t!inking )as influenced 0y 8reuds psyc!oanalysis model. 7n addition, early

neuro0iological models suggested t!at conversion reactions )ere related to conflicts, including

dangerous conflicts associated )it! fear. e!avioral models descri0ed conversion symptoms as

diseases of communication or a social construct )it! disagreement or lack of empat!y 0et)een patient

and doctor.

8reud coined t!e term conversionto signify t!e su0stitution of somatic symptoms for repressed

emotions. Historically, t!e terms conversion, !ysteria, and conversion !ysteria )ere used

interc!angea0ly to descri0e a condition c!aracteri/ed 0y a single somati/ed symptom, often a

pseudoneurologic one -eg, 0lindness.

Current perspectives

Hilgards neodissociation t!eory conceptuali/es cognitive !ierarc!y )it! e1ecutive structure

responsi0le for intentionality and a)areness linked )it! various su0ordinate structures in C$S, )it!

disruption of communication 0et)een centers 0eing responsi0le for negative and positive symptoms.

Ho)ever, its lack of e1planation of an underlying 0iologic pat!)ay and of guidance for intervention

limited its acceptance.

"ore recently, 9akleys attentional control model attempts to anc!or t!e cognitive processing

su0strate in a neuro0iologic su0strate )it! a !ierarc!y in t!e cere0ral corte1 t!en t!e e1ecutive

system, follo)ed 0y active representation of internal and e1ternal p!enomena. Ho)ever, independent

verification of t!e !ypot!eses cannot 0e done, )it! only partial support from neuroanatomic correlates

of cognitive processes. $e)er models also converge on t!e conceptuali/ation of conversion as


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reflecting errors in information processing and representation in t!e cognitive and neural systems are

underpinnings of t!e processes.

Nomenclature chanes

7n *+:%, t!e original DSM)as pu0lis!ed. Su0seuently, < editions !ave follo)ed and include t!e %nd

edition (DSM-II)in *+=&, t!e DSM-IIIin *+&', t!e DSM-IIIrevised edition (DSM-III-R)in *+&(, and t!e


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2!e symptom or deficit causes clinically significant distress or impairment in social,

occupational, or ot!er important areas of functioning or )arrants medical evaluation.

2!e symptom or deficit is not limited to pain or se1ual dysfunction, does not occur e1clusively

during t!e course of somati/ation disorder, and is not 0etter accounted for 0y anot!er mental

disorder.

2!e type of symptom or deficit s!ould 0e specified as follo)s# -* )it! motor symptom or deficit, -%

)it! sensory symptom or deficit, -> )it! sei/ure or convulsions, or -


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andor medicalcondition

course ofsomati/ation disorder;not 0etteraccountedfor 0y ot!ermentaldisorder

su0stanceeffect, orculturallysanctioned0e!avior andore1perience

Pain disorder Pain ispredominantfocus; severeenoug! to)arrant clinicalattention

Psyc!ologicalfactors inimportant role

$ot 0etteraccountedfor 0ymood,an1iety, orpsyc!otic

disorder;does notmeet criteriafordyspareunia

$ot specified

Hypoc!ondriasis

Preoccupation)it! fear of!aving or ideat!at one !as

serious disease0ased onmisinterpretationof 0odilysymptoms;persistent fearand idea despitemedicalevaluation andreassurance

Duration B=mo

$ote1clusivelyduringo0sessive

compulsivedisorder-9CD,generali/edan1iety,panicdisorder,ma?ordepressiveepisode,

separationan1iety, orot!ersomatoformdisorder

$ot ofdelusionalintensity; notrestricted to

circumscri0edconcern a0outappearance

ody Preoccupation $ot applica0le $ot 0etter $ot specified


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dysmorp!icdisorder

)it! imagineddefect inappearance ore1cessiveconcern a0outslig!t p!ysicalanomaly

accountedfor 0y ot!ermentaldisorder

Somatoformdisorder, notot!er)isespecified

Somatoformsymptoms

Can 0e = moduration

Does notmeet criteriafor anyot!ersomatoformdisorder

$ot specified

$ote.2o ualify for t!is category of diagnoses, t!e symptoms must cause clinically significant

distress or impairment in social, occupational, or ot!er areas of functioning.

Epidemiology

Eifetime prevalence rates in t!e general population are estimated to 0e **6>'' cases per *'','''

people.

Farying estimates of t!e prevalence of conversion disorders depend on met!odologic differences in

diagnosis as )ell as on procedures used to confirm t!e disorder in different studies.

Fre)uenc-

2!e prevalence is :6*G of patients referred to outpatient

psyc!iatric clinics, and :6%:G of psyc!iatric outpatients. $o specific c!ild!ood prevalence figures are

availa0le.

Se+

2!e prevalence is !ig!er in )omen t!an in men, )it! a female6to6male ratio of %6*'#*. Appro1imately

%:G of emotionally normal postpartum and medically ill )omen report conversion symptoms sometime

during t!eir lives.

Socioeconomic and ps-choloical factors


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Eo) socioeconomic status and lo) levels of psyc!ological sop!istication are associated )it! !ig!

prevalences, as evident in developing countries compared )it! developed countries. 2!e prevalence

may 0e as !ig! as >*G in some developing nations.

Familial pattern

Eimited data suggest t!at conversion disorder freuently occurs in relatives of individuals )it!

conversion disorder. Symptoms are often modeled from affected family mem0ers. 2!erefore, a

t!oroug! family !istory of medical conditions is essential. Case series s!o) an increased risk in

mono/ygotic 0ut not di/ygotic t)ins.

$ongenetic familial factors, suc! as incestuous se1ual a0use in c!ild!ood, may 0e associated )it! an

increased risk for conversion disorder. 2!e conversion disorder may 0e t!e only mec!anism for

communication t!at remains availa0le to t!e c!ild or adolescent.

'nset

2!e onset is generally from late c!ild!ood to early adult!ood, and t!e disorder rarely occurs in c!ildren

younger t!an *' years. Conversion disorder seldom develops for t!e first time after t!e fourt! decade

of life. 2!e onset is generally acute, 0ut symptoms may gradually increase.

Course

Data suggest t!at symptoms ameliorate in more t!an one !alf of all !ospitali/ed patients )it! t!is

disorder at t!e time of t!eir disc!arge. Ho)ever, %'6%:G !ave a relapse in one year. 7n general,

individual conversion symptoms are self6limited and do not lead to permanent seuelae or disa0ilities.

Pronosis

8actors associated )it! a good prognosis include t!e follo)ing#

Acute onset

Clearly identifia0le stressors at time of onset

S!ort interval 0et)een onset and starting treatment

@ood cognition and intelligence

Symptoms of ap!onia, paralysis, andor 0lindness -as opposed to sei/ures and tremor, )!ic!

are associated )it! a poor prognosis


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Diagnostic Considerations

Developmental considerations

Conversion disorder usually 0egins in t!e adolescent years and after. Presc!ool6aged c!ildren )!o are

developmentally !ealt!y often !ave apparent paresis )it!out a demonstrated p!ysiologic cause for a

fe) !ours or days after a minor in?ury.

Symptoms may elicit increased attention from parents and ot!er caregivers, leading to secondary gain.

2!ese symptoms are considered normal 0e!avior for c!ildren in t!is age group, and t!e role of

psyc!ological stressors is minimal. Psyc!iatric comor0idity !as 0een poorly studied, as reflected in

0ot! t!e c!ild and adolescent and t!e adult literature.

Ps-choloical considerations

Conversion reactions represent a form of communication of t!e uncomforta0le or, as 3ngel )rites, 4a

psyc!ic mec!anism )!ere0y an idea, fantasy, or )is! is e1pressed in 0odily rat!er t!an ver0al terms

and is e1perienced 0y t!e patient as a p!ysical symptom rat!er t!an as a mental symptom.4 Hollender

states, 4Conversion symptom is a code )!ic! conceals t!e message from t!e sender as )ell as from

t!e receiver.4 Conversion symptoms are e1perienced 0y t!e patient as involuntary and are often

mysterious and frig!tening to t!e patient.

Primary gain refers to t!e e1tent to )!ic! a conversion symptom diminis!es t!e unpleasant emotion

and communicates sym0olically t!e unconscious )is! 0y keeping t!e internal conflict out of

a)areness. Secondary gain is ac!ieved )!en t!e patient !as 0een removed from t!e uncomforta0le

situation 0y virtue of t!e symptom. 7nterference )it! daily activities also provides secondary gain to t!e

patient 0ecause attention and emotional support are often elicited from concerned parents and friends.

Ho)ever, identification of secondary gain from decreased functioning is not pat!ognomonic of a

diagnosis of conversion disorder. Conversion symptoms are more readily e1!i0ited in t!e presence of

t!ose individuals meaningful to t!e patient 0ecause perpetuation of secondary gain is contingent on

concern from ot!ers significant to t!e patient and t!e underlying causes of t!e symptom.

Neuroscience considerations

Attempts !ave 0een recently made, )it! t!e advent of functional imaging studies, to delineate t!e

neuroscience underpinnings of conversion disorder. 9ne !ypot!esis is t!at conversion is t!e result of


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dynamic reorgani/ation of neural circuits t!at link volition, movement, and perception. 3arly

electrop!ysiological studies implicate t!e anterior cingulate gyrus and possi0ly or0itofrontal corte1 as

responsi0le in 4active in!i0ition4. Ho)ever, functional "57 -f"57 and single6p!oton emission

computed tomograp!y -SP3C2 studies are still fe) and involve fe) su0?ects; !ence, t!ey are at a

preliminary stage and cannot 0e used to definitively propose a neuro0iological 0asis for conversion

disorder.

Makin the dianosis

Complicating factors in making t!e diagnosis of conversion disorder include t!e !ig!er6t!an6average

pro0a0ility of t!e presence of a coe1isting p!ysical illness 0ecause t!e % conditions are not mutually

e1clusive. Patients )it! incapacitating and frig!tening p!ysical illnesses may appear to e1aggerate

symptoms. At t!e same time, patients )it! actual neurologic illnesses may also e1!i0it conversion

symptoms.

"ore t!an one t!ird of individuals )it! conversion symptoms !ave a current or prior neurologic

condition -eg, c!ildren )it! a sei/ure disorder may also !ave pseudosei/ures. 2!us, p!ysicians must

recogni/e a possi0le comor0idity of conversion disorder along )it! a medical condition )!en faced

)it! a symptom profile t!at is difficult to interpret.

A presentation of possi0le conversion symptoms mandates a t!oroug! evaluation for t!e potential

underlying organic disease. 2!e e1tent of t!is evaluation involves t!e p!ysicians ?udgment. !en t!esymptoms suggest t!e possi0ility of conversion disorder, t!e evaluation s!ould include mental !ealt!

e1amination in addition to la0oratory and radiologic tests. 7n early studies, general medical etiologies

)ere later found in one fourt! to one t!ird of persons initially identified as !aving conversion

symptoms.

A systematic revie) of misdiagnosis of conversion symptoms in patients )!o )ere ultimately identified

as an organic medical condition !as improved over time. 9n average, studies in t!e *+:'s revealed

misdiagnosis rates around %+G )!ic! improved to *(G in t!e *+='s and !as 0een sta0le at around


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$o su0stitute for a good !istory and intervie) is kno)n. P!ysicians s!ould elicit family !istory,

stressors, family illness, conflicts in relations!ips, and unresolved grief over loss or separation. Sc!ool

performance and peer relations!ips s!ould also 0e considered. A !ealt!care provider mig!t inuire

a0out c!ange of sc!ool, e1aminations, and ne) social e1periences.

$ondirective intervie)ing is more re)arding t!an direct uestioning 0ecause it provides insig!ts into

emotions t!at t!e patient associates )it! t!e symptoms. Care s!ould 0e taken to avoid suggesting a

cause6and6effect relations!ip 0et)een t!e patients feelings and presenting symptoms. 3ncouraging

talk a0out life events !elps adolescents to volunteer personal feelings associated )it! somatic

symptoms.

Clinical Features

Conversion symptoms are most typically related to voluntary motor or sensory functioning and

t!erefore are referred to as pseudoneurologic symptoms. 2!ese are t!e most common type of

conversion symptoms. Conversion symptoms typically do not conform to kno)n anatomic pat!)ays

and p!ysiologic mec!anisms; instead, t!ey follo) t!e individuals conceptuali/ation of a medical

condition. Symptoms are often inconsistent -eg, a paraly/ed e1tremity is moved inadvertently )!en t!e

patient dresses or )!en !is or !er attention is directed else)!ere.

"otor conversion disorders primarily involve t!e ma?or muscle groups. eakness occurs more

freuently t!an dystonia. Presentations of )eakness include paralysis, paresis, and gait distur0ance.

7n conversion motor symptoms, paralysis can occur for a prolonged period )it!out atrop!y. Dystonic

presentations include spasmodic dysp!onia, torticollis, torsion, tremor, euinovarus, and gait

distur0ance. Additional symptoms may include ptosis, c!orea, ata1ia, glo0us !ystericus -difficulty

s)allo)ing, and astasia6a0asia -t!e ina0ility to stand or sit uprig!t 0ut an a0ility to move t!e legs

)!en lying do)n or sitting.

Sensory symptoms may include loss of touc! or pain sensation, dou0le vision, 0lindness, deafness,

and !allucinations.

Pseudosei/ures are t!e most commonly reported conversion symptoms in t!e c!ild and adolescent

psyc!iatric literature. 2!ey resem0le sudden convulsive events 0ut are not associated )it! 33@

evidence of a sei/ure, and t!ey do not follo) t!e typical pattern of a sei/ure disorder. Pseudosei/ures

can appear as t!e convulsive type, as !ysteroepilepsy -including t!e classic arc6de6cercle opist!otonic


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posture, as an atonic drop attack, or as unresponsiveness )it! complicated automatic 0e!avior and

myoclonus.

2a0le %. Differences 0et)een Pseudosei/ure and 2rue Sei/ure

Feature Pseudosei.ure &rue Sei.ure

Histor-

Pattern $o neurop!ysiologic pattern Same pattern

Precipitant 90vious emotional precipitantand occurrence in presence ofot!ers

Precipitant may 0e present0ut not o0vious; notassociated )it! presence

of ot!ers

Sleepassociation

Does not occur in sleep "ay occur in sleep

2reatment 7ntracta0le despite adeuatemedication

9ften responds tomedication

9t!er features History of se1ual or ot!era0use

History of incontinence orself6in?ury

'/servations

9nset @radual A0rupt

Duration Duration varia0le 0ut long -*'6*: min

S!ort duration *6%minutes

Consciousness Usually preserved )it! 0ilateralmotor activity; may 0efluctuating 0ut some responsiveto pain

Eost and unresponsive topain

Aura Unusual e1cept for symptomsof !yperventilation

Usual

"oaning S)oon or faint; may moan, cry, "onotonous, epileptic cry


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scream, or )eep

"ovements $onsync!ronous out6of6p!asemovements -may 0e mild, ?erky,side6to6side !ead movements,pelvic t!rusting, limping,motionless, unresponsive;opist!otonic posturing or rigidityfor e1tended periods

@enerali/ed tonic6clonicmovements starting )it!fast, small amplitudemovements to slo), largemovements; 0rief rigidity,supplementarymovements -eg, arms ina0duction.

During sleep Uncommon during p!ysiologicsleep

"ay occur

7n?ury Self6protection 0efore fall;

seldom self6in?ury

8reuent self6in?ury -eg,

0ite tongue, !it !ead, !urtlim0

5efle1es $o pat!ologic refle1es a0inski refle1 andpupillary constriction aftersei/ure

Postictalconfusion

Eittle and patient isunconcerned

Postictal confusion ortransient paralysis

Amnesia etter memory for event; non6organic amnesia

Amnesia

7n front ofsignificantot!ers

Usually occurs Unconcerned

7ndependent)itness

A0sent Present

7nduction 0ysuggestion

5eadily induced or stopped $ot readily induced orstopped

$ot readily induced 0y sleep,p!otic stimuli, sleepdeprivation, !yperventilation

Precipitated 0y sleep,p!otic stimuli, sleepdeprivation,!yperventilation


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9t!ero0servations

Avoidance 0e!avior, arm drop,eye opening, genotropicmovement

Seeking !elp, tiredness,0lank look, pupillaryrefle1es

&estin

pH immediatelyafter attack

$ormal "ay c!ange

Creatininekinase afterattack

$ormal 5ises -significant ifpositive

Prolactin afterattack

$ormal 5ises -significant ifpositive

33@ $o epileptic6form disc!arge,maintenance of alp!a r!yt!m)it! only discontinuous muscleactivity record during attackand a0sence of slo)ing )it!immediate reappearance ofprevious alp!a r!yt!m; 33@may 0e a0normal in *'6:>G,)it! prompt clinical and 33@

recovery from a generali/edconvulsive episode

3pileptic c!anges in mostpatients -video6monitored33@ IF33@J preferred;takes time to recover-F33@ useful

Provocativemet!ods

Psyc!iatric intervie),suggestion, place0omedication, or !ypnosis

Hyperventilation, p!oticstimuli, or sleepdeprivation

Associated features

a !elle indifferenceis defined as a relative lack of concern a0out t!e nature or implications of t!e

symptom manifested on t!e part of t!e patient. "ore commonly o0served in adults, la !elle

indifferenceis rarely o0served in c!ildren and adolescents -as fe) as &G. C!ildren and adolescents

may typically e1press fear and !opelessness regarding t!eir lack of voluntary control over t!e

symptoms. a !elle indifferencemay 0e present in individuals )it! com0inations of medical conditions

and conversion disorders. 9ccasionally, individuals )it! conversion symptoms may present in a

dramatic or !istrionic fas!ion.


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Ho)ever, evidence from pu0lis!ed literature suggests t!at la !elle indifferenceis not an useful clinical

sign for distinguis!ing conversion symptoms from organic disease. 5ecommendations !ave 0een

made to a0andon its use as a clinical sign until more rigorous studies are done to clarify its definition

and use in diagnostics. 7ts use !as endured, regardless, due to its 4cac!e4 name and possi0ility of a

link to 0iological rig!t !emisp!ere dysfunction t!at !as yet to 0e proven )it! functional imaging

studies.

Differential Diagnoses

Medical conditions

"edical conditions t!at may mimic conversion symptoms include t!e follo)ing#

"ultiple sclerosis -)it! 0lindness secondary to optic neuritis

"yast!enia gravis -)it! muscle )eakness

Periodic paralysis -)it! muscle )eakness

"yopat!ies -)it! muscle )eakness

Polymyositis -)it! muscle )eakness

@uillain6arr syndrome -motor and sometimes sensory

Ps-chiatric conditions

Psyc!iatric conditions t!at must 0e differentiated include t!e follo)ing#

Dissociative disorder

Psyc!otic disorders

"ood disorders

8actitious disorders and malingering

Pain disorder or se1ual dysfunction

Somati/ation disorder

Undifferentiated somatoform disorder

Considering ot!er somatoform disorders )!ile attempting to make a diagnosis of conversion disorder

is al)ays important.

Differentiation of hallucinations in conversion and other ps-chiatric disorders


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7n general, conversion disorder !allucinations differ from psyc!otic !allucinations and sometimes are

referred to as pseudo!allucinations.

2a0le >. Hallucinations in Conversion Disorder Fersus 9t!er Psyc!iatric Disorders

Characteristic Conversion Disorder Ps-chotic Disorder

9t!er psyc!oticsymptoms

2ypical a0sence of ot!erpsyc!otic symptoms -eg,disordered t!oug!tprocess

Disordered t!oug!t process

7nsig!t into!allucinations

7nsig!t retained t!at!allucinations are not real

2ypical lack of insig!t a0outunreality of !allucinations

Scope of!allucinations

Hallucinations involvingmore t!an one sensorymodality

2ypical !allucinationsinvolving single sensorymodality, especially auditoryand secondarily tactile orvisual

Psyc!ologicalmeaning of!allucinations

Hallucinations oftenpsyc!ologicallymeaningful

Hallucinations often 0i/arreand unrelated topsyc!ological factors

Figilance must 0e maintained for emergence of ot!er signs of psyc!osis in a diagnosed case of

conversion disorder; psyc!otic !allucinations may s!are some of t!e features of conversion

!allucinations.

Dissociative identity disorder and posttraumatic stress disorder and sc!i/op!renia are psyc!iatric

disorders )it! !allucinations t!at must 0e differentiated from conversion disorder.

Treatment

Primar- care ph-sician

"ost commonly, c!ildren and adolescents )it! conversion disorder present to t!e pediatrician or

primary !ealt! care provider 0ecause t!e presentation of illness is almost al)ays medical, p!ysical, or

0ot!. C!ildren usually undergo varying degrees of medical )orkup depending on t!eir presenting

symptoms and on t!e level of comfort and e1pertise of t!e provider.


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8amily mem0ers and patients initially 0elieve t!at an undiagnosed medical cause for t!e symptoms is

responsi0le, and t!ey are not comforta0le )it! a provisional diagnosis of conversion disorder from t!eir

p!ysician. 2!e tasks of a primary care p!ysicians include providing education a0out conversion

disorder )!ile carefully ruling out contri0uting medical conditions and attending to t!e vie)s of t!e

patient and !is or !er family.

A discussion of t!e interplay 0et)een emotional and p!ysical stress can 0e !elpful to t!e patient and

!is or !er family. 2!e clinician s!ould encourage t!e family to openly communicate a0out t!e

diagnostic tests t!at t!ey )ould like performed and a0out t!e medical conditions t!at t!ey 0elieve are

causing t!e symptoms. 31plain to t!e family t!at, even )!ile t!e symptoms persist, t!e goal is to !elp

t!e c!ild or adolescent to maintain normal daily functioning in sc!ool and in t!eir social life )it! peers.

5eferral to a professional trained in mental !ealt! diagnosis and treatment may 0e necessary if

progress is not made in coping )it! symptoms.

2!e p!ysician s!ould discuss )it! t!e patient and t!e families t!e close interrelation 0et)een p!ysical

and emotional factors. 3very individual !as an emotional response to a p!ysical stress. Similarly,

everyone !as a p!ysical )ay of responding to emotional stress. 2!e p!ysician can provide t!e

e1ample of !eadac!es developing )!en individuals 0ecome upset. People )it!out medical training

can easily understand t!is e1ample. 2!e empat!etic approac! and open ackno)ledgment of t!is

interplay 0y t!e p!ysician can !elp t!e family volunteer information a0out psyc!osocial functioning.

8ocusing on organic diagnosis alone suggests t!at psyc!ological involvement is unlikely, unimportant,and impro0a0le. y looking at psyc!ological issues alone, t!e p!ysician implies t!at t!is is t!e last

resort 0ecause t!e p!ysician )as una0le to ascertain an organic cause. Hence, t!e concurrent

p!ysiopsyc!ological approac! is 0est. 2!e p!ysician must 0e satisfied )it! t!e completeness of t!e

p!ysical evaluation and s!ould use discretion regarding t!e e1tent of t!e organic )orkup.

Alt!oug! patients )it! conversion disorder are suggesti0le, reassurance t!at symptoms )ill go a)ay is

rarely effective; t!is reassurance does not !elp pro0e t!e psyc!ological source of t!e symptoms. 9n

t!e contrary, suggesting t!at symptoms )ill persist may provide time to esta0lis! t!erapeutic

relations!ips. Use of place0o medication is usually ineffective and et!ically uestiona0le. 2!e patient

s!ould 0e allo)ed to eliminate t!e symptoms andor signs as slo)ly as is needed and )it! dignity.

A pediatrician )!o encounters a conversion disorder in a c!ild or adolescent is most successful )!en

!e or s!e advocates a team approac!, including ot!er !ealt!care providers )!o can openly

communicate and )ork toget!er.


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(eferrals

Appropriate referrals are made to 0e!avioral pediatricians, c!ild and adolescent psyc!iatric clinics,

community mental !ealt! centers, private mental !ealt! professionals, and community social support

agencies.

Mental health professionals

5eferrals to psyc!iatrists, psyc!ologists, and 0e!avioral pediatricians usually come from sc!ool

personnel, court officials, and c!ildrens )elfare agencies. Primary p!ysicians may refer patients after

t!e initial )orkup is completed if an organic condition cannot 0e documented.

"odalities used to treat conversion disorder may include individual psyc!ot!erapy, group and family

t!erapy, and p!armacologic approac!es to manage specific symptoms.

Psyc!odynamic tec!niues !elp a c!ild gain insig!t into unconscious conflicts and understand !o)

psyc!ological factors !ave !elped to maintain symptoms. Cognitive60e!avioral approac!es and

0e!avior modification plans !ave also 0een attempted. Parado1ical intention, )!ic! is encouraging t!e

patient to deli0erately engage in t!e un)anted 0e!avior, !as 0een studied as !as !ypnosis. 2!erapists

also use antian1iety approac!es in t!e form of progressive muscle rela1ation, visual imagery, and

0iofeed0ack, as )ell as antian1iety medication.

Case reports !ave detailed interventions as diverse as spa treatment, surgery, electroconvulsive

t!erapy, p!ysiot!erapy, and inpatient psyc!iatric care.

Ho)ever, fe) studies s!o) t!e effectiveness -or lack t!ereof of psyc!osocial interventions. 7n a

systematic revie) of studies to investigate efficacy of psyc!osocial intervention on conversion disorder,

only > small studies )ere found, most )it! met!odological pro0lems and inconclusive results.

@oals of family and group t!erapy include 0uilding self6esteem, promoting assertiveness, improving

communication )it! family and peer groups, and teac!ing nonsomatic )ays to e1press distress. @roup

t!erapy is particularly !elpful in learning social skills, decreasing dependency on t!e family, and

learning coping strategies.

3ducational and p!armacologic interventions may 0e needed to treat underlying depressive and

an1iety disorders, as )ell as educational pro0lems. Hospitali/ation is sometimes indicated if outpatient

t!erapy is not effective. Some clinicians advocate inpatient t!erapy as t!e primary site to initiate

treatment 0ecause it removes c!ildren from t!eir environments. 7npatient treatment may facilitate a


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more appropriate level of functioning and more adaptive responses. 7npatient treatment is geared

to)ard ruling out significant organic issues and promoting certain types of functioning a)ay from t!e

!ome environment.

Pronosis

8ollo)6up studies indicate an eventual full recovery in &:6+(G of c!ildren. 3arly recognition and

prompt intervention are often associated )it! speeded recovery. 8avora0le prognostic features are a

recent onset of symptoms, a monosymptomatic manifestation, and a good premor0id personality.

Prognosis !as 0een suggested to 0e poorer )it! nonepileptic attacks, tremor, or amnesia rat!er t!an

!ysterical 0lindness, ap!onia, and motor disorders.

References

*. APA. Somatoform disorders. Conversion disorder. 7n# Diagnostic and Statistical Manual of

Mental Disorders. %+6>&. I"edlineJ.

:. @!affar 9, Staines 5, 8einstein A. Une1plained neurologic symptoms# an f"57 study of

sensory conversion disorder. 'eurolog#. Dec *% %''=;=(-**#%'>=6&. I"edlineJ.

=. Ko/lo)ska K. Healing t!e disem0odied mind# contemporary models of conversion

disorder. arv Rev "s#chiatr#. Lan68e0 %'':;*>-*#*6*>. I"edlineJ.

(. Krem "". "otor conversion disorders revie)ed from a neuropsyc!iatric perspective. % Clin

"s#chiatr#. Lun %''6+'.I"edlineJ.

&. "ailis6@agnon A, @iannoylis 7, Do)nar L, et al. Altered central somatosensory processing in

c!ronic pain patients )it! 4!ysterical4 anest!esia. 'eurolog#. "ay *> %''>;='-+#*:'*6

(.I"edlineJ.
http://www.medscape.com/medline/abstract/15297682http://www.medscape.com/medline/abstract/15297682http://www.medscape.com/medline/abstract/2581282http://www.medscape.com/medline/abstract/2581282http://www.medscape.com/medline/abstract/9334545http://www.medscape.com/medline/abstract/17159115http://www.medscape.com/medline/abstract/17159115http://www.medscape.com/medline/abstract/15804930http://www.medscape.com/medline/abstract/15804930http://www.medscape.com/medline/abstract/15291655http://www.medscape.com/medline/abstract/15291655http://www.medscape.com/medline/abstract/12743239http://www.medscape.com/medline/abstract/12743239http://www.medscape.com/medline/abstract/15297682http://www.medscape.com/medline/abstract/2581282http://www.medscape.com/medline/abstract/9334545http://www.medscape.com/medline/abstract/17159115http://www.medscape.com/medline/abstract/15804930http://www.medscape.com/medline/abstract/15291655http://www.medscape.com/medline/abstract/12743239


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+. "artin 5, Mut/y S. Somatoform disorders. 7n#&$erican "s#chiatric "ress e*t!oo+ of

"s#chiatr#. >rded. as!ington, DC# American Psyc!iatric Press; *+++.

*'. "inuc!in S, aker E, 5osman E, et al. A conceptual model of psyc!osomatic illness in

c!ildren. 8amily organi/ation and family t!erapy.&rch en "s#chiatr#. Aug *+(:;>%-*'>*6

&.I"edlineJ.

**. $emia! LC. Somatoform disorders. 7n# Sadock L, Sadock FA, eds. a.lan and Sadoc+/s

Co$.rehensive e*t!oo+ of "s#chiatr#. . Pe!livanturk , Unal 8. Conversion disorder in c!ildren and adolescents# a >*-(:%>#+&+. I"edlineJ.

*(. Stone L, Smyt! 5, Carson A, arlo) C, S!arpe ". Ea 0elle indifference in conversion

symptoms and !ysteria# systematic revie). 2r % "s#chiatr#. "ar %''=;*&%'


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a0asia, !ysteroepilepsy, pseudosei/ures, la !elle indifference, !allucinations, posttraumatic stress

disorder, sc!i/op!renia

Contriutor Information and Disclosures

Aut!or

Neelkamal S Soares, MD, FAAP,Assistant Professor, Department of Pediatrics, University of

Kentucky; Consulting Staff, Department of Pediatrics, Kentucky Clinic

$eelkamal S Soares, "D, 8AAP is a mem0er of t!e follo)ing medical societies# American Academy of

Pediatrics, Kentucky Pediatric Society, and Society for Developmental and e!avioral Pediatrics

Disclosure# $ot!ing to disclose

Coaut!or

Linda Grossman, MD,Associate Professor, Division Head, Department of Pediatrics, Division of

e!avioral and Developmental Pediatrics, University of "aryland Sc!ool of "edicine

Einda @rossman, "D is a mem0er of t!e follo)ing medical societies# Am0ulatory Pediatric Association


"edical Editor

Carol Diane erko0it., MD,31ecutive Fice C!air, Department of Pediatrics, Professor, Har0or6

University of California at Eos Angeles "edical Center

Carol Diane erko)it/, "D is a mem0er of t!e follo)ing medical societies# Alp!a 9mega Alp!a,

Am0ulatory Pediatric Association, American Academy of Pediatrics, American College of 3mergency

P!ysicians, American "edical Association, American Pediatric Society, and $ort! American Society for

Pediatric and Adolescent @ynecology


#!armacy Editor

Mar- L 1indle, PharmD,Ad?unct Assistant Professor, University of $e0raska "edical Center Collegeof P!armacy, P!armacy 3ditor, e"edicine.com, 7nc

Disclosure# Pfi/er 7nc Stock for 7nvestment from 0roker recommendation; Avanir P!arma Stock for

7nvestment from 0roker recommendation

"anaging Editor


21/21

Carol- Pataki, MD,Professor of Clinical Psyc!iatry, Department of Psyc!iatry and io0e!avioral

Sciences, Division C!air of C!ild and Adolescent Psyc!iatry, Director of 2raining, C!ild and Adolescent

Psyc!iatry 5esidency Program, University of Sout!ern California Keck Sc!ool of "edicine

Caroly Pataki, "D is a mem0er of t!e follo)ing medical societies# American Academy of C!ild and

Adolescent Psyc!iatry, $e) Mork Academy of Sciences, and P!ysicians for Social 5esponsi0ility


C"E Editor

Carrie S-lvester, MD, MPH,Director of 3ducation in C!ild and Adolescent Psyc!iatry, Professor,

Departments of Psyc!iatry and Pediatrics, $ort!)estern University "edical Sc!ool

Carrie Sylvester, "D, "PH is a mem0er of t!e follo)ing medical societies# American Academy of C!ild

and Adolescent Psyc!iatry, American Academy of Pediatrics, American "edical omens Association,

American Psyc!iatric Association, and American Society for Adolescent Psyc!iatry


C!ief Editor

Carol- Pataki, MD,Professor of Clinical Psyc!iatry, Department of Psyc!iatry and io0e!avioral

Sciences, Division C!air of C!ild and Adolescent Psyc!iatry, Director of 2raining, C!ild and Adolescent

Psyc!iatry 5esidency Program, University of Sout!ern California Keck Sc!ool of "edicine

Caroly Pataki, "D is a mem0er of t!e follo)ing medical societies# American Academy of C!ild and

Adolescent Psyc!iatry, $e) Mork Academy of Sciences, and P!ysicians for Social 5esponsi0ilityDisclosure# $ot!ing to disclose

O *++

somatoform disorder conversion

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