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Let’s take a closer look now at the Somatic Symptom and Other Disorders as they’ve been newly
classified in the DSM-5. So somatic symptom disorder diagnosis, you are looking for the following
diagnostic criteria. One or more symptomatic symptoms that cause distress or psychological
impairment. Also excessive thoughts, feelings, or behaviors associated with the somatic symptoms
demonstrated by one or more of these. Either persistent thoughts about the seriousness of
symptoms, persistent severe anxiety about the symptoms or one’s general health, the time and
energy devoted to the symptoms or health concerns is excessive and although the specific somatic
symptoms may change, the disorder is persistent for more than a 6-month period. Illness anxiety
disorder diagnosis is as follows: A preoccupation with having or acquiring a serious undiagnosed
illness. Somatic symptoms are mild or non-existent. There is substantial anxiety about one's
health and it’s either excessive behaviors related to health or maladaptive avoidance of situations
or activities that are thought to represent health threats. The illness preoccupation is present
for at least 6 months and the illness preoccupation is not better explained by another mental
disorder or a general medical condition. So let’s consider this case example. “An elderly man
comes to his primary care office complaining of anxiety due to motor problems. Numbness and
tingling in his extremities and nausea over the past few months.” What do you think of his
diagnosis? Actually, a key here is that this man is elderly so in the case of older individuals
somatic symptoms are actually going to be most likely due to an organic cause or an actual medical
problem. So you want to be careful not to just attribute something to a psychiatric reason, always
keep that in mind, you always have to rule out general medical conditions. Conversion disorder
and other psychiatric etiology should always be the last thing on your mind when it comes to
your patients. Let’s talk a little bit now about conversion disorder, though conversion involves
the presence of symptoms or deficits that affect voluntary motor or sensory function in a fashion
that suggests a neurological condition but which is not explained by any medical findings. So
the patient will have at least 1 neurological symptom either sensory or motor and it cannot be
explained by a medical disorder. They may not be able to connect if the onset of the disorder
might be preceded or exacerbated by some kind of a psychological stressor and it’s often a fact
that the patient is surprisingly calm or even indifferent about their symptoms. We call this
la belle indifference. When describing their symptoms, they just show very little regard and
seem a little bit aloof to what’s happening even when it’s a serous symptom like blindness or
paralysis. Check out this case study. “A 30-year-old woman visits her doctor complaining of
blindness 1 week after she walked in on her husband having an affair. There are no abnormalities
on her exam and a neurology and ophthalmology work-up is negative. So here you may be suspecting
a conversion disorder. Right? She saw something she didn’t want to see, it’s a major psychological
stress and all of a sudden she’s complaining of blindness. In the 1900s, who first described
conversion disorder? Well, that’s Jean Martin Charcot. He taught in Paris and he really linked
conversion symptoms to trauma. Later, Sigmund Freud looked at the importance of the unconscious
process and his analysis of patients and he wrote about the famous case study “Dora” who is a
woman with hysteria and most conversion disorder symptoms were actually manifested by her as
aphonia or loss of voice. If a patient presents with neurological or motor complaints in older
age, remember it’s most likely a neurological problem, not a psychiatric problem. So going on a
little bit further about conversion disorder, let’s talk about its epidemiology. So it’s fairly
common associated with a traumatic event. It has about a 25% incidence in general medical settings
and it tends to be more common in women than in men. The onset can be at any age but usually
it’s adolescence or early adulthood. There’s an increased incidence and low socio-economic
groups and there’s a high comorbidity of schizophrenia, major depression and anxiety disorders
that comes along with it. So how does it develop? Well, there’s a dynamic hypothesis that says
that conversion disorder is a solution to an unconscious conflict. There is also consideration
that there could be alterations in brain structure and function specifically in the right
hemisphere. Some people think that hypercritical families and developments can contribute to
unspeakable dilemmas that later lead to conversion disorder. Then there’s a suggestibility
theory where here people think that individuals who are highly suggestible and don’t always
have a great sense of self are going to be more likely to develop a conversion disorder. So,
some comorbidity factors that go along with conversion include depression, somatization, dissociation,
personality disorders and maybe a childhood trauma. You must rule out general medical conditions
whenever you see any of the following comments, signs, or symptoms that go along with conversion:
a shifting paralysis, sudden blindness, mutism, paresthesias, seizures, or globus hystericus.
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Some of the treatment for conversion includes an insight-oriented psychotherapy. This really
relies on a conversation between the therapist and the patient and helps people get through
this time by talking about and expressing their feelings, emotions and beliefs and understanding
their unconscious process. Some people believe hypnosis can be helpful, which is a state of
human consciousness involving focused attention and reduced peripheral awareness and an enhanced
capacity to respond to suggestion. Then there’s also relaxation therapy where people can attain
state of increased calmness and this can be very helpful as well in conversion disorder.