14: Clinical and Laboratory Tests to Distinguish Conversion Disorder and Malingering from Organic Disease

INTRODUCTION

I. THE GENERAL CLINICAL FEATURES OF CONVERSION DISORDER AND MALINGERING

A. Definition of conversion disorder

Conversion disorder (previously referred to as hysteria) means a temporary disorder of mental, voluntary motor, or sensory functions that mimics neurologic disease but is caused by unconscious determinants, not by organic lesions in the neuroanatomic sites that should produce the dysfunctions. Table 14–1 reviews some common dysfunctions in patients with conversion disorder.

B. Primary and secondary gain

Classic psychoanalytic theory holds that conversion disorders arise from unconscious mental mechanisms that relieve overwhelming anxiety by converting it into symptoms (Weintraub, 1995; Woolsey, 1976). The symptom provides primary and secondary gains for the Pt.

1. The primary gain consists of the relief of anxiety.

2. The secondary gains consist of manipulative control over the emotional responses, attention, and actions of other persons and relief from responsibilities. Apparently the gains make the symptom more acceptable to the Pt than the anxiety that the symptom relieves.

3. Walker et al. (1989) suggested that operant conditioning, with its theory of reinforcement of behavior by reward, provides an alternative paradigm to psychoanalytic theory. They stated "Simply put, those behaviors that obtain reward are those that are expressed."

C. Distinction between conversion disorder, factitious disorder, and malingering

1. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. (DSM-IV) distinguishes between conversion disorder factitious disorder, and malingering for Pts who have symptoms and signs that are not caused by organic disease. In conversion disorder, the dysfunction and the purposes it serves seem to arise at a subconscious level, but the Pt experiences the illness as genuine. At the opposite pole stands the frank malingerer who consciously fakes an illness to achieve some tangible external goal, such as getting money in a lawsuit or avoiding criminal prosecution. The DMS-IV Text Revision (DSM-IV-TR) recognizes three main types of factitious disorders: (1) factitious disorders with predominantly psychological signs and symptoms, (2) factitious disorders with predominantly physical signs and symptoms, and (3) factitious disorders ...