Much will be gained if we succeed in transforming your hysterical misery into common unhappiness. —Sigmund Freud (1856–1939)
I. THE GENERAL CLINICAL FEATURES OF CONVERSION DISORDER (FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER)
A. Definition of conversion disorder
Conversion disorder (functional neurologic symptom disorder, DSM-5, 2013) 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 (American Psychiatric Association, 2013). The diagnosis of functional neurologic symptom disorder remains problematic for the clinician (Allanson et al, 2002; LaFrance, 2009; Nicholson et al, 2011). Table 14-1 reviews some common dysfunctions in patients with conversion disorder (functional neurologic symptom disorder). Malingering is not considered a mental illness.
TABLE 14-1Symptoms and Signs of Functional Neurologic Symptom Disorder |Favorite Table|Download (.pdf) TABLE 14-1 Symptoms and Signs of Functional Neurologic Symptom Disorder
Amnestic and fugue states
Paralysis (monoplegia, paraplegia, or hemiplegia)
Hyperkinesia: tremors, flailing, and spasms
Hyperventilation, often with dizziness and syncope; weak, shallow respiration; or grunting, demonstrative respiration
Blepharospasm, convergence spasm, pseudo-VIth nerve palsy, and ptosis
Anesthesia, paresthesia, hyperesthesia, or pain
Dimness of vision, tunnel vision and spiral fields, blindness, double vision, and photophobia
Deafness and dizziness
Multisystem complaints, especially gastrointestinal, genitourinary, and reproductive system/sexual/menstrual
B. Primary and secondary gain
Classic psychoanalytic theory holds that functional neurologic symptom disorders arise from unconscious mental mechanisms that relieve overwhelming anxiety by converting it into symptoms (Meyers and Volbrecht, 2003; Weintraub, 1995; Woolsey, 1976). The symptom provides primary and secondary gains for the Pt.
The primary gain consists of the relief of anxiety.
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.
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
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) distinguished between conversion disorder factitious disorder, and malingering for Pts who had symptoms and signs not caused by organic disease (American Psychiatric Association, 1994). The DMS-IV Text Revision (DSM-IV-TR) recognized 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 with combined psychological and physical signs and symptoms. Factitious disorder (formerly known as Munchausen syndrome) a chronic variant of factitious ...