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[09 Jan 2003|10:01am] |
im juss copying this here for when i get home. im at school right now..and i cant email this info.
III. Conversion Disorder
A. Definition: Conversion disorder is a disorder characterized by the presence of one or more neurological symptoms, that cannot be explained by a known neurological or medical disorder. In addition, the diagnosis requires that psychological factors be associated with the initiation or exacerbation of the symptoms.
B. History
1. Charcot, Breuer and Freud in the late 19th century and early 20th
2. "Conversion reaction" in DSM
3. "Hysterical neurosis, conversion type" in DSM-II
4. DSM-III and DSM-III-R: characterized by symptoms involving any "loss of, or alteration in, physical functioning suggesting a physical disorder so long as the mechanism of "conversion" was evident.
C. Epidemiology
1. Lifetime prevalence rates range from 11/100,000 to 300/100,000
2. From under 5% to 24% of psychiatric outpatients
3. 5% to 15% of general hospital patients
4. 1% to 3% of outpatient psychiatric referrals
5. Nearly 10% of outpatient psychiatric referrals in developing countries are for conversion symptoms.
6. 25% to 30% of admissions to a Veterans Affairs Hospital
7. The ratio of women to men adult patients is at least 2 to 1 and as much as 5 to 1
8. Children have an even higher predominance of girls
9. Men with conversion disorder often involved in occupational or military accidents
10. Onset: any age
11. More common in rural population, little-educated, low IQ, low socioeconomic groups, military personnel who have been exposed to combat situations
12. Commonly associated with major depression, anxiety disorder and schizophrenia
D. Etiology
1. The term conversion derives from the hypothesized "conversion" of psychological conflict into a somatic symptom.
2. 1/3 with history of sexual abuse, especially incestuous.
3. Often the youngest, or else the youngest of a sex, in sibling order
4. Conversion symptoms are more frequent in relatives of individuals with conversion disorder with rates 10 times greater in female relatives, and approximately five times in male relatives
5. Psychoanalytic factors: repression and conversion.
6. Biological factors:
a) Hypometabolism of the dominant hemisphere and hypermetabolism of the non-dominant hemisphere, have impaired hemispheric communications is the cause of conversion disorder
b) The symptoms may be caused by an excessive cortical arousal that set negative feedback loops between the cerebral cortex and the brainstem reticular formation
E. Clinical Features
1. Sensory Symptoms: anesthesia, paresthesia, deafness, blindness, tunnel vision
2. Motor Symptoms: abnormal movements, gait disturbances (astasia-abasia), weakness, paralysis, paresis, tremors, jerks
3. Seizures
4. "Primary gain": anxiety is theoretically reduced by keeping an internal conflict or need out of awareness by symbolic expression of an unconscious wish as a conversion symptom.
5. "Secondary gain": whereby conversion symptoms allow avoidance of noxious activities or the obtaining of otherwise unavailable support
6. Individuals with conversion disorder may show a lack of concern out of keeping with the nature or implications of the symptom (the so called la belle indifference).
7. Conversion symptoms may present in a dramatic or histrionic fashion and may be highly suggestible.
8. Identification
F. Diagnostic Criteria for Conversion Disorder
As defined in DSM-IV, nonintentional “symptoms or deficits affecting voluntary motor or sensory function” are central to conversion disorder. Pseudoneurological symptoms remain the classic symptoms.
DSM-IV
A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
B. 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 stressors.
C. The symptoms or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a
culturally sanctioned behavior or experience.
E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better
accounted for by another mental disorder.
Specify type of symptom or deficit:
With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation
G. Differential Diagnosis
1. 20%-50% patients with conversion symptoms have neurological illness on follow-up.
2. Physical illness and conversion are not mutually exclusive.
3. The most reliable predictor is a history of previous conversion disorder.
4. Conversion symptoms first occurring in middle age should increase suspicion.
5. Neurological / Physical Medical Disorder
a) MS (consider blindness secondary to optic neuritis with initially normal fundi)
b) Guillain-Barre syndrome, (weakness of the arms and legs may be inconsistent)
c) Myasthenia gravis
d) Periodic paralysis
e) Myoglobinuric myopathy
f) Polymyositis
g) Other acquired myopathies (all of which may present with marked weakness in the presence of normal deep tendon reflexes)
6. "Hallucinations" vs. "pseudohallucinations
7. Non-psychiatric Medical Disorders
8. Somatization, Hypochondriasis, Pain, Malingering and Factitious Disorders
H. Course and Prognosis
1. Onset is generally from late childhood to early adulthood.
2. Onset is generally acute but may have gradually increasing symptomatology.
3. Self-limited, occasionally, physical sequelae such as atrophy may occur.
4. 90% to 100% of patients’ initial symptoms resolve in a few days or less than a month.
5. 75% may not experience another episode.
6. 25% to 50% of patients may later have a neurological or nonpsychiatric medical etiology.
7. 20% to 25% will relapse within 1 year.
8. Good prognosis: acute onset, presence of clearly identifiable stress at the time of onset, a short interval between onset and institution of treatment, good premorbid adjustment, no comorbid psychiatric or medical condition, no ongoing litigation, and good intelligence. Symptoms of blindness, aphonia, and paralysis.
9. Poorer prognosis: seizures and tremor
I. Treatment
1. Generally, the initial aim in treatment is the removal of the symptom.
2. Direct confrontation is not recommended (hello).
3. A conservative approach of reassurance and relaxation is effective.
4. Narcoanalysis (e.g., amobarbital interview), hypnosis, and behavior therapy
5. The influence of suggestion (Hypnosis).
6. Psychodynamic psychotherapy
7. Brief and direct short term psychotherapy
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