SOMATIC SYMPTOM AND RELATED DISORDERS

SOMATIC SYMPTOM DISORDER

Another case study (Barlow & Durand)
Linda, a woman in her 30s, went to a clinic looking distressed and pained. As she sat down she noted that
coming into the office was difficult for her because she had trouble breathing and considerable swelling
in the joints of her legs and arms. She said she knew they would have to go through a detailed initial
interview, but she had something that might save time. She pulled out several sheets of paper and handed
them over. One section described her contacts with the health-care system for major difficulties only.
Times, dates, potential diagnoses, and days hospitalized were noted. The second section consisted of a list
of all medications she had taken for various complaints. Linda felt she had any one of a number of
chronic infections that nobody could properly diagnose. Linda’s entire life revolved around her
symptoms. She once told her therapist that her symptoms were her identity: without them she would not
know who she was. By this she meant that she would not know how to relate to people except in the
context of discussing her symptoms much as other people might talk about their day at the office or their
kids’ accomplishments at school.
She had begun to have these problems in her teenage years. She often discussed her symptoms and fears
with doctors and clergy. Drawn to hospitals and medical clinics, she had entered nursing school after high
school. During hospital training, however, she noticed her physical condition deteriorating rapidly: she
seemed to pick up the diseases she was learning about. A series of stressful emotional events resulted in
her leaving nursing school. After developing unexplained paralysis in her legs, Linda was admitted to a
psychiatric hospital, and after a year she regained her ability to walk. On discharge she obtained disability
status, which freed her from having to work full time, and she volunteered at the local hospital. With her
chronic but fluctuating incapacitation, on some days she could go in and on some days she could not.
Historical Overview:

● Psychophysiological autonomic and visceral disorders in DSM I: Exaggerated Physiological

reactions due to expression of symptoms lead to changes in anatomy of the body, eg: ulcers,
lumps being formed
● DSM II: Psychophysiological Disorders- Diagnostic criteria and understanding of the disorder
largely remained the same.
● DSM III: Psychophysiological Disorders category was dropped.

Categories of (a) Psychological factors affecting physical conditions, coded on axis 2.

Psychological factors are responsible for the initiation, exacerbation or exaggeration of physical
symptoms.

(b) Somatoform disorders: Coded on Axis 1, there were physical symptoms but physiological
dysfunction was not responsible for them

Disorders included- Somatization, Hypochondriasis and Conversion Disorders

● DSM IV: Psychological factors affecting physical conditions was renamed to Psychological
factors affecting medical conditions.

Somatoform Disorders were retained. Disorders included Somatization, undifferentiated SF disorders

conversion disorder, pain disorder, hypochondriasis, body dysmorphic, somatoform disorder NOS.

● DSM V: Renamed to Somatic Symptom and Related Disorders

Disorders include

● somatic symptoms disorder,

● illness anxiety disorder,
● conversion disorder,
● psychological factors affecting other medical conditions,
● factitious disorder,
● other specified somatic symptom and related disorder,
● unspecified somatic symptoms and related disorder.

DISSOCIATIVE IDENTITY DISORDER

Dissociative disorders involve dissociation, an unconscious defense mechanism, involving the
segregation of any group of mental or behavioral processes from the rest of the person’s
psychic activity so that there is a disruption in one or more mental functions, such as memory,
identity, perception, consciousness, or motor behavior. The disturbance may be sudden or
gradual, transient or chronic, and the cause is often psychological trauma.

(EXTRA and GENERAL FOR ALL DISSOCIATIVE DISORDERS) Dissociative symptoms are
experienced as
a) unbidden intrusions into awareness and behavior, with losses of continuity in subjective
experience (i.e., ‘‘positive’’ dissociative symptoms such as fragmentation of identity,
depersonalization, and derealization)
and/or
b) inability to access information (i.e., “negative’’ dissociative symptoms such as amnesia).

DISSOCIATIVE DISORDERS INCLUDE:

● - DID
● - Dissociative amnesia with specifier of dissociative fugue
● - Depersonalisation/Derealisation disorder
● - Other specified dissociative disorder
● - Unspecified dissociative disorder

- Definition
Dissociative identity disorder is the presence of two or more distinct identities or personality
states. The identities or personality states, called alters, differ from one another in that each
presents as having its pattern of perceiving, relating to, and thinking about the environment
and self, in short, its personality.
It is the paradigmatic dissociative psychopathology in that the symptoms of all the other
dissociative disorders occur in patients with dissociative identity disorder: amnesia, often with
fugue, depersonalization, derealization, and similar symptoms.

Diagnostic Criteria (as per DSM 5)

A. Disruption of identity characterized by two or more distinct personality states, which

may be described in some cultures as an experience of possession. The disruption in
identity involves marked discontinuity in sense of self and sense of agency,
accompanied by related alterations in affect, behavior, consciousness, memory,
perception, cognition, and/or sensory-motor functioning. These signs and symptoms
may be observed by others or reported by the individual.
 B. Recurrent gaps in the recall of everyday events, important personal information, and/ or
traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious

practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other
fantasy play.

E. The symptoms are not attributable to the physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or another medical condition
(e.g., complex partial seizures).

Clinical Features (Important characteristics, nature and age of onset, course

and duration of illness, differential diagnosis, co-morbidity, sex ratio,
prognosis)

CHARACTERISTICS:
Dissociative identity disorder is characterized by
a. the presence of two or more distinct personality states or an experience of pathological
possession and
ALTERS:

● Two or more personalities are alters. There can be upto 100 alters
● The identity that we most frequently encounter is the host identity. It carries the
name of the real identity. It is not the best adjusted identity.
● The alter identities may differ in many ways including gender, preference of
using hands, handwriting, sexual orientation, prescription for eye glasses,
predominant affect, langauges spoken, general awareness
● There may be shifts in the sense of self- attitudes, outlooks and preference
changes- and shift back
● There is also a shift in the sense of agency - feeling of not being in control of
their thoughts, feelings and actions
● Switching involves one alter taking over the other

b. recurrent episodes of amnesia.

AMNESIA: Lack/loss of memory- manifests as total amnesia wherein the alters are not
aware of the presence of other alters
 ● It can also manifest as co-consciousness where some alters are aware of other
alters
● Gaps in the memory of past personal life events. They are not necessarily
traumatic events
● Lapses in skills and abilities because other alters may not have those skills which
the host does
● Discovery of evidence of their everyday actions which they do not recollect
doing

The fragmentation of identity may vary with culture (e.g., possession-form presentations) and
circumstance. Individuals may experience discontinuities in identity and memory that may
not be immediately evident to others or are obscured by attempts to hide dysfunction.

Individuals with dissociative identity disorder also experience

a. recurrent, inexplicable intrusions into their conscious functioning and sense of self
(e.g., voices; dissociated actions and speech; intrusive thoughts, emotions, and impulses),
b. alterations of sense of self (e.g., attitudes, preferences, and feeling like one’s body or
actions are not one’s own),
c. odd changes of perception (e.g., depersonalization or derealization, such as feeling
detached from one’s body while cutting), and
d. intermittent functional neurological symptoms. Stress often produces transient
exacerbation of dissociative symptoms that makes them more evident.

Pathological possession was also added in the diagnostic criteria for DID in DSM 5. A trance is
said to occur when someone experiences a temporary marked alteration in state of
consciousness or identity. A possession trance is similar except that the alteration of
consciousness or identity is replaced by a new identity that is attributed to the influence of a
spirit, deity, or other power. In both cases amnesia is typically present for the trance state.
When entered into voluntarily for religious or spiritual reasons, trance and possession states are
not considered pathological. However, when they occur involuntarily, outside accepted
cultural contexts, and cause distress, this is a serious problem, as in DID.
Pathological possession is a common form of DID in Africa, Asia, and many other non-
Western cultures (Spiegel et al., 2013). This important change makes the diagnosis of DID
more inclusive and applicable to a broader range of cultural groups.

(ADDED BECAUSE DISCUSSED BY PB EXTENSIVELY)

NATURE AND AGE OF ONSET:

The onset is almost always in childhood, often as young as 4 years of age, although it is usually
approximately 7 years after the appearance of symptoms before the disorder is identified
(Maldonado et al., 1998; Putnam et al., 1986).
COURSE AND DURATION:
Once established, the disorder tends to last a lifetime in the absence of treatment. The form
DID takes does not seem to vary substantially over the person’s lifespan, although some
evidence indicates the frequency of switching decreases with age (Sackeim & Devanand,
1991). Different personalities may emerge in response to new life situations.

DIFFERENTIAL DIAGNOSIS:
Major depressive disorder: Individuals with DID are often depressed. However, this
depression in some cases does not meet full criteria for major depressive disorder. Other
specified depressive disorder in individuals with dissociative identity disorder often has an
important feature- the depressed mood and cognitions fluctuate because they are experienced
in some identity states but not others.

Bipolar disorders: Individuals with dissociative identity disorder are often misdiagnosed with a
bipolar disorder, most often bipolar II disorder. The relatively rapid shifts in mood in
individuals with this disorder—typically within minutes or hours, in contrast to the slower
mood changes typically seen in individuals with bipolar disorders—are due to the rapid,
subjective shifts in mood commonly reported across dissociative states, sometimes accompanied
by fluctuation in levels of activation.

Posttraumatic stress disorder: Some individuals have both PTSD and DID.
Accordingly, it is crucial to distinguish between individuals with PTSD only and individuals who
have both PTSD and dissociative identity disorder. This differential diagnosis requires that the
clinician establish the presence or absence of dissociative symptoms that are not
characteristic of acute stress disorder or PTSD.
Some individuals with PTSD manifest dissociative symptoms that also occur in dissociative
identity disorder: 1) amnesia for some aspects of trauma, 2) dissociative flashbacks (i.e., reliving
of the trauma, with reduced awareness of one’s current orientation), and 3) symptoms of
intrusion and avoidance, negative alterations in cognition and mood, and hyperarousal that are
focused around the traumatic event.

Likewise individuals with dissociative identity disorder manifest dissociative symptoms that are
not a manifestation of PTSD: 1) amnesias for many everyday (i.e., nontraumatic) events, 2)
dissociative flashbacks that may be followed by amnesia for the content of the flashback, 3)
disruptive intrusions (unrelated to traumatic material) by dissociated identity states into the
individual’s sense of self and agency, and 4) infrequent, full-blown changes among different
identity states.
Conversion disorder (functional neurological symptom disorder). This disorder may be
distinguished from dissociative identity disorder by the absence of an identity disruption
characterized by two or more distinct personality states or an experience of possession.
Dissociative amnesia in conversion disorder is more limited and circumscribed (e.g., amnesia
for a non-epileptic seizure).

Psychotic disorders: Dissociative identity disorder may be confused with schizophrenia or other
psychotic disorders. They have personified, internally communicative inner voices which may be
mistaken for psychotic hallucinations. Dissociative experiences of identity fragmentation or
possession, and of perceived loss of control over thoughts, feelings, impulses, and acts, may be
confused with signs of formal thought disorder, such as thought insertion or withdrawal.
Individuals with dissociative identity disorder may also report visual, tactile, olfactory,
gustatory, and somatic hallucinations, which are usually related to posttraumatic and
dissociative factors, such as partial flashbacks.
Individuals with dissociative identity disorder experience these symptoms as caused by
alternate identities, do not have delusional explanations for the phenomena, and often
describe the symptoms in a personified way (e.g., “I feel like someone else wants to cry with
my eyes”). Chaotic identity change and acute intrusions that disrupt thought processes may be
distinguished from brief psychotic disorder by the predominance of dissociative symptoms
and amnesia for the episode, and diagnostic evaluation after cessation of the crisis can help
confirm the diagnosis.

Personality disorders: Individuals with dissociative identity disorder often present identities
that appear to encapsulate a variety of severe personality disorder features. Importantly,
however, the individual’s longitudinal variability in personality style (due to inconsistency
among identities) differs from the pervasive and persistent dysfunction in affect management
and interpersonal relationships typical of personality disorders.

(NOT DONE IN DETAIL BY PB)

Substance/medication-induced disorders: Symptoms associated with the physiological effects
of a substance can be distinguished from dissociative identity disorder if the substance in
question is judged to be etiologically related to the disturbance.

Seizure disorders. Individuals with dissociative identity disorder may present with seizure like
symptoms and behaviors that resemble complex partial seizures with temporal lobe foci. Normal
electroencephalographic findings, including telemetry, differentiate non-epileptic seizures from
the seizurelike symptoms of dissociative identity disorder. Also, individuals with dissociative
identity disorder obtain very high dissociation scores, whereas individuals with complex partial
seizures do not.
Factitious disorder and malingering. Individuals who feign dissociative identity disorder do
not report the subtle symptoms of intrusion characteristic of the disorder; instead they tend to
overreport well-publicized symptoms of the disorder, such as dissociative amnesia, while
underreporting less-publicized comorbid symptoms, such as depression. Individuals who feign
dissociative identity disorder tend to be relatively undisturbed by or may even seem to enjoy
“having” the disorder. In contrast, individuals with genuine dissociative identity disorder tend to
be ashamed of and overwhelmed by their symptoms and to underreport their symptoms or deny
their condition. Sequential observation, corroborating history, and intensive psychometric and
psychological assessment may be helpful in assessment.

Other specified dissociative disorder: The central feature of DID of division of identity is
shared with one form of other specified dissociative disorder, which may be distinguished from
dissociative identity disorder by the presence of chronic or recurrent mixed dissociative
symptoms that do not meet Criterion A for dissociative identity disorder or are not accompanied
by recurrent amnesia.

COMORBIDITY:
Many individuals with dissociative identity disorder present with a comorbid disorder. If not
assessed and treated specifically for the dissociative disorder, these individuals often receive
prolonged treatment for the comorbid diagnosis only, with limited overall treatment
response and resultant demoralization, and disability.
Individuals with dissociative identity disorder usually exhibit a large number of comorbid
disorders including PTSD, depressive disorders, trauma- and stressor-related disorders,
personality disorders, conversion disorder, somatic symptom disorder, eating disorders,
substance-related disorders, obsessive compulsive disorder, and sleep disorders.
Dissociative alterations in identity, memory, and consciousness may affect the symptom
presentation of comorbid disorders.

SEX RATIO:
Approximately three to nine times more females than males are diagnosed as having the
disorder, and females tend to have a larger number of alters than do males (Maldonado &
Spiegel, 2007).
This pronounced gender discrepancy could be due to the much greater proportion of childhood
sexual abuse among females than among males, but this is a highly controversial point.

(FROM DSM) Females with dissociative identity disorder predominate in adult clinical settings
but not in child clinical settings. Adult males with dissociative identity disorder may deny their
symptoms and trauma histories, and this can lead to elevated rates of false negative diagnosis.
Females with dissociative identity disorder present more frequently with acute dissociative states
(e.g., flashbacks, amnesia, fugue, functional neurological [conversion] symptoms, hallucinations,
self-mutilation). Males commonly exhibit more criminal or violent behavior than females;
among males, common triggers of acute dissociative states include combat, prison conditions,
and physical or sexual assaults.

PROGNOSIS:
Ongoing abuse, later-life retraumatization, comorbidity with mental disorders, severe
medical illness, and delay in appropriate treatment are associated with poorer prognosis.

- Case study:
Case of Jonah, originally reported by Ludwig, Brandsma, Wilbur, Bendfeldt, and Jameson
(1972).

Jethalal (kyun) , a 47 years old man, suffered from severe headaches that were unbearably
painful and lasted for increasingly longer periods. Furthermore, he couldn’t remember things
that happened while he had a headache, except that sometimes a great deal of time passed.
Finally, after a particularly bad episode, he arranged for admission to the local hospital. During
Jethalal’s hospitalization, the staff was able to observe his behavior directly, both when he had
headaches and during other periods that he did not remember.
He claimed other names at these times, acted differently, and generally seemed to be another
person entirely. The staff distinguished three separate identities, or alters, in addition to Jonah.
The first alter was named Sammy. Sammy seemed rational, calm, and in control. The second
alter, King Young, seemed to be in charge of all sexual activity and was particularly interested
in having as many heterosexual interactions as possible. The third alter was the violent and
dangerous Usoffa Abdulla. Characteristically, Jonah knew nothing of the three alters. Sammy
was most aware of the other personalities. King Young and Usoffa Abdulla knew a little bit
about the others but only indirectly.

- Epidemiology

Prevalence:
The 12-month prevalence of dissociative identity disorder among adults in a small U.S.
community study was 1.5%. The prevalence across genders in that study was 1.6% for males
and 1.4% for females.
Although systematic studies are lacking, DID seems to occur in a variety of cultures
throughout the world, particularly in terms of experiencing possession, which is one
manifestation of DID (Boon & Draijer, 1993; Coons, Bowman, Kluft, & Milstein, 1991; Ross,
1997). Coons and colleagues (1991) found reports of DID in 21 different countries.
Posession syndrome and trance syndrome are prevalent in other cultures.
DID is diagnosed much more commonly by clinicians in North America than in Europe.
This fact has engendered a long- running dispute. European clinicians (naturally) claim that the
disorder is rare, and that by paying so much attention to patients who dissociate, New World
clinicians actually encourage the development of cases.

- Causation
Biological Factors:
1. Basic heritable traits, such as tension and responsiveness to stress, may increase
vulnerability to DID.
2. There is some evidence of smaller hippocampal and amygdala volume in patients with
DID compared with “normals” (Vermetten, Schmahl, Lindner, Loewenstein, & Bremner,
2006).
3. Head injury and resulting brain damage may induce amnesia or other types of
dissociative experience. But these conditions are usually easily diagnosed because they
are generalized and irreversible and are associated with an identifiable head trauma
(Butler et al., 1996).
4. strong evidence exists that sleep deprivation produces dissociative symptoms such as
marked hallucinatory activity (Giesbrecht et al., 2007; van der Kloet, Giesbrecht, Lynn,
Merckelbach, & de Zutter, 2012). In fact, the symptoms of individuals with DID seem to
worsen when they feel tired. Simeon and Abugal (2006) report that patients with DID
“often liken it to bad jet lag and feel much worse when they travel across time zones”
5. Patients with dissociative experiences who have seizure disorders are clearly different
from those who do not (Ross, 1997). The seizure patients develop dissociative symptoms
in adulthood that are not associated with trauma, in clear contrast to DID patients
without seizure disorders.

Psychological Factors:
1. The structural model of personality dissociation (Steele, Vander Hart,
Nijenhuis, 2001)
● It states that as a response to a traumatic event, certain parts of the personality develop
which form a certain part of the self i.e. they get separated from the self rather than
integrating with the self.
● Emotional Personality (EPs) remains separated and recurrently suffers vivid
sensorimotor experiences that closely match the original trauma. They are emotionally
laden and are generated with trauma. They become fixed and remain split off from
the self.
 ● The rest of the parts are known as the Apparently Normal Personality (ANPs) and are
associated with avoidance of the traumatic memories, detachment, numbing, and
partial or complete amnesia.
● (The term personality in ANP and EP denotes dissociative part of the patient’s
personality at large)
● ANP and EP are insufficiently integrated, but interact and share a number of
dispositions of the personality (e.g., speaking). All parts are stuck in maladaptive
action tendencies that maintain dissociation.

2. Psychoanalytic Theory:
The Psychoanalytic theory points to oral Regression in case of DID.
The psychodynamic theory of dissociative disorders assumes that dissociative disorders are
caused by an individual’s repressed thoughts and feelings related to an unpleasant or
traumatic event (Richardson, 1998). In blocking these thoughts and feelings, the individual is
subconsciously protecting themself from painful memories.

The defense mechanisms involved in DID are:

- Ego Splitting: It is a vertical barrier wherein consciousness gets divided and the alters
know each other.
- Denial: recognizing that something is happening but denying that it is not really
happening and splitting from the bodily experience of trauma. Children who are not
sufficiently protected in the face of trauma in early childhood are more likely to use
denial.
 3. Social Cognitive theory:
According to this theory, DID develops when a highly suggestible person learns to adopt and
enact the roles of multiple identities, mostly because clinicians have inadvertently suggested,
legitimized, and reinforced them and because these different identities are geared to the
individual’s own personal goals (Lilienfeld & Lynn, 2003; Lilienfeld et al., 1999; Spanos,
1994, 1996).
It is important to understand that the sociocognitive perspective does not view this as being done
intentionally or consciously by the person involved. Rather, it occurs spontaneously with little
or no awareness (Lilienfeld et al., 1999). The suspicion is that clinicians, through fascination
with the clinical phenomenon of DID and unwise use of such techniques as hypnosis, are
themselves largely responsible for eliciting this disorder in highly suggestible, fantasy-prone
people.

CONVERSION DISORDER
(Functional Neurological Symptom Disorder)
Belongs to a new category in DSM-5 called somatic symptom and related disorders- includes
the diagnoses of somatic symptom disorder, illness anxiety disorder, conversion disorder
(functional neurological symptom disorder), psychological factors affecting other medical
conditions, factitious disorder, other specified somatic symptom and related disorder, and
unspecified somatic symptom and related disorder. All of the disorders share a common feature:
the prominence of somatic symptoms associated with significant distress and impairment.
soma means body. Physical symptoms do not have physiological causation.

1. INTRODUCTION

It is characterized by the presence of neurological symptoms in the absence of a neurological

diagnosis (see Feinstein, 2011).
A few typical examples include partial paralysis, blindness, deafness, and episodes of limb
shaking accompanied by impairment or loss of consciousness that resemble seizures.
ccf
The diagnosis can only be made after a full medical and neurological workup has been
conducted.

It is also important to emphasize that the person is not intentionally producing or faking the
symptoms. Rather, psychological factors are often judged to play an important role because
symptoms usually either start or are exacerbated by preceding emotional or interpersonal
conflicts or stressors.

2. CLINICAL PICTURE

A. Diagnostic criteria (DSM-5)

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the
symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or
mental disorder.
D. The symptom or deficit causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.

Specifiers:
With weakness or paralysis
With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gait disorder)
With swallowing symptoms
With speech symptom (e.g., dysphonia, slurred speech)
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptom (e.g., visual, olfactory, or hearing disturbance)
With mixed symptoms
Specify if:
Acute episode: Symptoms present for less than 6 months.
Persistent: Symptoms occurring for 6 months or more.
Specify if:
With psychological stressor (specify stressor)
Without psychological stressor

B. Clinical Features
 In describing the clinical picture in conversion disorder, it is useful to think in terms
of four categories of symptoms:
1. sensory- sensory symptoms or deficits are most often in the visual system
(especially blindness and tunnel vision), in the auditory system (especially
deafness), or in the sensitivity to feeling especially the anesthesias. In the
anesthesias, the person loses her or his sense of feeling in a part of the body.
One of the most common is glove anesthesia, in which the person cannot feel
anything on the hand in the area where gloves are worn.
2. motor- conversion paralysis is usually confined to a single limb such as an arm
or a leg, and the loss of function is usually selective for certain functions. The
most common speech-related conversion disturbance is aphonia, in which a
person is able to talk only in a whisper. Another common symptom, called
globus, involves the sensation of a lump in the throat.
3. seizures- Another relatively common form of conversion symptom involves
seizures. These resemble epileptic seizures, although they are not true seizures.
patients do not show any EEG abnormalities and do not show confusion and
loss of memory afterward. often show excessive thrashing about and writhing
not seen with true seizures,
4. a mixed presentation of the first three categories (APA, 2013).

Onset and Duration: It can develop at any age but most commonly occurs
between early adolescence and early adulthood (Maldonado & Spiegel, 2001).
It generally has a rapid onset after a significant stressor and often resolves within
2 weeks if the stressor is removed, although it commonly recurs (Merkler et al.,
2015).

Differential diagnosis:
1. Neurological disease. The main differential diagnosis is neurological
disease that might better explain the symptoms especially if the
symptoms appear to be progressive. Conversion disorder may coexist
with neurological disease.
2. Somatic symptom disorder. Most of the somatic symptoms encountered
in somatic symptom disorder cannot be demonstrated to be clearly
incompatible with pathophysiology (e.g., pain, fatigue), whereas in
conversion disorder, such incompatibility is required for the diagnosis.
The excessive thoughts, feelings, and behaviors characterizing somatic
symptom disorder are often absent in conversion disorder.
3. Factitious disorder and malingering. The diagnosis of conversion
disorder does not require the judgment that the symptoms are not
intentionally produced (i.e., not feigned), because assessment of
conscious intention is unreliable.
 4. Body dysmorphic disorder. Individuals with body dysmorphic disorder
do not complain of symptoms of sensory or motor functioning in the
affected body part.

Comorbidity
Anxiety disorders, especially panic disorder, and depressive disorders
commonly co-occur with conversion disorder. Somatic symptom disorder may
co-occur as well. Personality disorders are more common in individuals with
conversion disorder than in the general population. Neurological or other
medical conditions commonly coexist with conversion disorder as well.

C. Epidemiology

Prevalence: Conversion disorders are found in approximately 5 percent of people

referred for treatment at neurology clinics. The prevalence in the general
population is unknown, but even the highest estimates have been around only
0.005 percent (APA, 2013). Tends to occur in less educated, lower
socioeconomic groups.

Sex ratio: Conversion disorder occurs two to three times more often in women
than in men (APA, 2013).

Risk Factors:

Temperamental. Maladaptive personality traits are commonly associated with

conversion disorder.

Environmental. There may be a history of childhood abuse and neglect.

Stressful life events are often, but not always, present.

Genetic and physiological. The presence of neurological disease that causes

similar symptoms is a risk factor (e.g., non-epileptic seizures are more common
in patients who also have epilepsy).

D. Case Study

Unable to See for Seven Days

 The patient, a 21-year-old university student came to the hospital, accompanied
by her mother. She said that she had not been able to see for the past week. An
ophthalmologic exam was done, followed by a neurological examination. Both
failed to reveal any specific problems.

Questioning by clinic staff revealed that, 1 month earlier, the patient had been
unable to speak for 2 weeks. Her inability to speak developed during a time
when she had been experiencing difficulties in her studies and a few hours after
her mother told her that her father had a life-threatening illness.

Eight months before her current presentation at the clinic, the patient had been
voiceless for another period of 6 weeks. At that time, she had received a
laryngoscopy, which revealed nothing abnormal. The patient was treated with
valium and also given some therapy to help her manage her stress and anxiety.

These same stress management techniques were used this time to help the
patient with her loss of vision. She was also offered materials suitable for a blind
person and asked to complete tactile tasks, making patterns with different
shapes. A little later she was given painting materials. Although the patient said
that she could not see what she was doing, she was able to reproduce shapes and
wrap paper around pieces of wood to make pearls for a necklace. Finally, after
3 weeks, she was able to see normally again. (Mulugeta et al., 2015.)

CLINICAL DYNAMICS (Etiology/ Causal Factors)

PSYCHOLOGICAL

Conversion disorders are thought to develop as a result of stress or internal conflicts of some
kind. Freud described four basic processes in the development of conversion disorder.

1. The individual experiences a traumatic event—in Freud’s view, an unacceptable,

unconscious conflict.

2. Because the conflict and the resulting anxiety are unacceptable, the person represses the
conflict, making it unconscious.
 3. The anxiety continues to increase and threatens to emerge into consciousness, and the
person “converts” it into physical symptoms, thereby relieving the pressure of having
to deal directly with the conflict. This reduction of anxiety is considered to be the
primary gain or reinforcing event that maintains the conversion symptom.

4. The individual receives greatly increased attention and sympathy from loved ones
and may also be allowed to avoid a difficult situation or task. Freud considered such
attention or avoidance to be the secondary gain, the secondarily reinforcing set of
events.

Most often, individuals with conversion disorder have experienced a traumatic event that must
be escaped at all costs including a history of sexual abuse, recent parental divorce or death of
a close family member, and physical abuse.

Early observations dating back to Freud suggested that most people with conversion disorder
showed very little of the anxiety and fear that would be expected in a person with a paralyzed
arm or loss of sight. This seeming lack of concern was known as la belle indifférence—French
for “the beautiful indifference.” For a long time it was thought to be an important diagnostic
criterion for conversion disorder. However, la belle indifférence occurs only in about 20 percent
of patients. Lack of concern about symptoms or their implications is also not specific to
conversion disorder. For these reasons, this phenomenon has become de-emphasized in more
recent editions of the DSM.

SOCIO-CULTURAL
Social and cultural influences also contribute to conversion disorder, which, like somatic
symptom disorder, tends to occur in less educated, lower socioeconomic groups where
knowledge about disease and medical illness is not well developed.

Prior experience with real physical problems, usually among other family members, tends to
influence the later choice of specific conversion symptoms; that is, patients tend to adopt
symptoms with which they are familiar.

Interestingly, this decreased prevalence seems to be closely related to our growing sophistication
about medical and psychological disorders: Conversion disorder apparently loses its defensive
function if it can be readily shown to lack a medical basis.

BIOLOGICAL
Individuals may have a marked biological vulnerability to develop conversion disorder when
under stress.
Neuroscientists are increasingly finding a strong connectivity between the conversion
symptom and parts of the brain regulating emotion, such as the amygdala, using brain-
imaging procedures. Many recent researches are consistent with the idea that sensory areas of
brain may perhaps be inhibited by overactive emotion based processing leading to somatic
symptoms.