CONVERSION DISORDER

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CONVERSION DISORDER
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• Formerly known as "hysteria", the disorder has
  arguably been known for millennia, though it came
  to greatest prominence at the end of the 19th
  century, when the neurologist Jean-Martin
  Charcot, and psychiatrists Pierre Janet and
  Sigmund Freud made it the focus of their study.

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• The term "conversion" has its origins in Freud's
  doctrine that anxiety is "converted" into
  physical symptoms.

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Definition

• DSM-IV defines conversion disorder as follows
• One or more symptoms or deficits are present that
  affect voluntary motor or sensory function
  suggestive of a neurological or other general
  medical condition.
• Psychological factors are judged, in the
  clinician's belief, to be associated with the
  symptom or deficit because conflicts or other
  stressors precede the initiation or exacerbation
  of the symptom or deficit. A diagnosis where the
  stressor precedes the onset of symptoms by up to
  15 years is not unusual.

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• The symptom or deficit is not intentionally
  produced or feigned
• The symptom or deficit, after appropriate
  investigation, cannot be explained fully by a
  general medical condition, the direct effects of
  a substance, or as a culturally sanctioned
  behavior or experience.
• The symptom or deficit causes clinically
  significant distress or impairment in social,
  occupational, or other important areas of
  functioning or warrants medical evaluation.

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• The nature of the association between the
  psychological factors and the neurological
  symptoms remains unclear. Earlier versions of the
  DSM-IV employed psychodynamic concepts, but these
  have been incrementally removed from successive
  versions. The ICD-10 classifies conversion
  disorder as dissociative (conversion) disorder,
  which suggests the symptoms arise through the
  process of dissociation

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History

• The term "Conversion disorder" originated with
  Freud. He viewed these apparently neurological
  symptoms as a result of the conversion of
  intrapsychic distress in to physical symptoms.
• The affected body part was seen as a symbolic
  infantile sex organ.

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Presentation

• Conversion disorder can present with any motor or
  sensory symptom including any of the following
• Weakness/paralysis of a limb or the entire body
  (hysterical paralysis or motor conversion
  disorders)
• Impaired hearing or vision
• Loss/disturbance of sensation
• Impairment or loss of speech (hysterical aphonia)
  
• Psychogenic non-epileptic seizures
• Fixed dystonia unlike normal dystonia
• Tremor, or other movement disorders
• Gait problems
• Syncope (fainting)

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Diagnosis

• The diagnosis of conversion disorder involves
  three elements
• the exclusion of neurological disease,
• the exclusion of feigning,
• and the determination of a psychological
  mechanism

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Epidemiology

• Prevalence
• Large scale psychiatric registers in the US and
  Iceland found rates of 22 and 11 per 100000 per
  year, respectively,34 but it is unclear what
  proportion of unexplained symptoms these
  represent.
• Culture
• A community survey of urban Turkey found a rate
  of 5.6.
• Many authors have found rates to be higher in
  rural and lower socio-economic groups where
  technological investigation of patients is
  limited

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• Gender
• 'Hysteria' was originally understood to be a
  condition exclusively affecting women, though it
  has increasingly been recognized in men.
• In recent, larger studies women continue to
  predominate, with between 2 and 6 female patients
  for every male.
• Age
• Conversion disorder may present at any age but is
  rare in children younger than 10 years or in the
  elderly.
• Studies suggest a peak onset in the mid-to-late
  30s.

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Symptom Groupings

• Sensory Symptoms
• These include anesthesia, excessive
  sensitivity to strong  simulation loss of sense
  of pain (analgesia), and unusual symptoms such as
  tingling or crawling sensations. Motor
  Symptoms
• In motor symptoms, any of the body's muscle
  groups may be involved arms, legs, vocal chords.
  Included are tremors, tics (involuntary
  twitches), and disorganized mobility or
  paralysis. Visceral Symptoms
• Examples are trouble swallowing, frequent
  belching, spells of coughing or vomiting, all
  carried to an uncommon extreme. In both sensory
  and motor symptoms

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• Specify type of symptom or deficit
• With Motor Symptom or Deficit.With Seizures or
  Convulsions.With Sensory Symptom or
  Deficit.With Mixed Presentation.
• Associated Features
• Depressed Mood.Somatic or Sexual
  Dysfunction.Guilt or Obsession.Anxious or
  Fearful or Dependent Personality.

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Treatment

• Explanation. This must be clear and coherent as
  attributing physical symptoms to a psychological
  cause is not accepted by many educated people in
  western cultures. It must emphasize the
  genuineness of the condition, that it is common,
  potentially reversible and does not mean that the
  sufferer is a "psycho".
• Physiotherapy where appropriate
• Treatment of comorbid depression or anxiety if
  present.
• There is little evidence-based treatment of
  conversion disorder. Other treatments such as
  cognitive behavioral therapy, hypnosis, and
  psychodynamic psychotherapy need further trials.