Clinical features
Conversion disorder
Conversion disorder (previously hysteria) is a condition where the person has neurological symptoms, but no neurological cause can be found. Sigmund Freud initially suggested that the cause of conversion disorder was the “conversion” of psychological distress into physical symptoms, but later decided that this was incorrect.
The underlying cause is still not clear, but is likely to be multifactorial and include both emotional distress and social factors. Brain scans show that the frontal lobe of the brain inhibits the action mediating parts of the brain, such as the motor cortex.
There are 4 categories-:
- With motor symptoms or deficit. This includes inco-ordation of gait (astasia – abasia), paralysis, tremor, abnormal movements and globus hystericus (difficulty in swallowing).
- With sensory symptoms or deficit. This includes blindness, deafness, sensory loss or altered sensation.
- With seizures or convulsions (pseudoseizures). This includes seizures or convulsions not caused by an epileptic fit.
- With mixed presentation if symptoms of more than one of the above categories are present.
People with conversion disorder may demonstrate the following features that can help to differentiate them from people with other neurological disorders:
The symptoms are not consistent with known pathological mechanisms. For example, sensory loss does not conform to the known sensory distribution of a particular nerve.
They may be highly suggestible and the symptoms vary in response to comments made by other people, or illnesses of people known to them.
They may demonstrate a relative lack of concern about the seriousness of their symptoms (“la belle indifference”), although this does not protect them from anxiety and depression.
Somatisation disorder
Somatisation disorder is a condition where the person has multiple longstanding (at least 2 years and onset before age 30) physical symptoms that have no underlying physical cause but the person still attributes them to a physical disease, in spite of medical reassurance.
People with somatisation disorder frequently have other psychiatric conditions, for example depressive disorder.
The cause is thought to be due to the person initially interpreting physical symptoms as being of sinister significance. Anxiety and concern cause the person to focus on the symptoms which are reinforced by subsequent behavioural, physiological and psychological responses in the person and the reactions of treating clinicians and other people.
People with somatisation disorder may complain of any physical symptom and the symptoms may refer to any bodily system or part of the body. The commonest symptoms are non specific, for example nausea, pain, dizziness and palpitations. The description of symptoms is often vague and inconsistent. People with somatisation are often suggestible and “learn” their symptoms from other patients. The symptoms usually change over time. Often they are focussed on one bodily system at a time (for example symptoms relating to the gastrointestinal tract) but a new set of symptoms will emerge (for example symptoms relating to the cardiovascular system) when all investigations and treatment options have been concluded for the first bodily system.
People with somatisation disorder may deny emotional symptoms or blame them on their physical symptoms. However, most people exhibit emotional symptoms eventually. The most frequent emotional symptoms are anxiety and depression.
Suicide attempts are frequent but suicide is uncommon. Substance abuse is common.
People with somatisation disorder are high users of medical services and in chronic cases will have been subject to a large number of investigations and treatments. They will frequently move from doctor to doctor (doctor shopping) in order to find a cure for their illness and there may be subsequent hostility between doctor and the person.
In chronic cases the person’s social and family life may be centred around and adjusted to the demands of the person’s illness (illness as a way of living or illness behaviour).
Hypochondriasis
Hypochondriasis is a condition where the person has a fear or belief that they have a serious disease in spite of medical reassurance. Physical examinations and investigation do not find a cause for the person’s symptoms or signs and the belief persists despite medical reassurance. The difference between hypochondriasis and somatisation disorder is that in hypochondriasis the person is preoccupied with only one or two possible physical disorders whereas the person with somatisation is preoccupied with multiple and changing physical disorders.
The cause is similar to that for somatisation disorder.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD or dysmorphophobia) is a distressing and/or impairing preoccupation with a non existent or slight defect in appearance (size or shape of a body part).
It is particularly common in dermatology and cosmetic surgery patients and in people with obsessive compulsive disorder, social phobia and depressive disorder.
The cause is not known but it is probably multifactorial, involving abnormalities of brain neurotransmitters (serotonin) similar to those of obsessive compulsive disorder together with stressors such as teasing about appearance.
People with BDD are preoccupied with the idea that some aspect of their appearance is unattractive, deformed or “not right” in some way. The commonest preoccupations relate to the skin, nose, ears, mouth, breasts, buttocks or thighs but any part of the body can be affected. The preoccupations are distressing, time consuming and usually difficult to resist and control. Before treatment, insight is usually poor or absent i.e. the person is convinced that their view of the defect is correct and they cannot be convinced otherwise. Occasionally BDD may be psychotic in its intensity. More than 90% perform compulsions to examine, improve or hide the perceived defect. The most common compulsions involve comparing themselves to others, checking in the mirror, applying makeup, camouflaging, dieting, exercise and seeking medical and surgical treatment. The majority of people with BDD seek costly non psychiatric treatment, usually from dermatologists and surgeons, but are usually dissatisfied with the treatment.
The level of disability varies widely. Some people may function well despite their symptoms but some may be housebound and chronically suicidal. There is almost always some degree of social isolation. They may avoid other people and may avoid specific locations such as restaurants or beaches where they may feel especially self conscious about their appearance. They often underachieve both educationally and in employment. BDD is strongly associated with depressive disorder (lifetime rate of more than 80%). Other associated psychiatric disorders include social phobia, substance abuse and obsessive compulsive disorder.
Pain disorder
Somatoform pain disorder is a condition where the person has chronic pain that is sufficiently severe to cause distress or impairment of functioning and for which no physical cause is found and emotional factors are thought to be causative or maintaining.
The cause of pain disorder is multifactorial and includes inappropriate beliefs (e.g. that the pain is harmful or disabling, life should be pain free, doctors should be able to cure it), anxiety about the pain (can I cope?) and increased bodily awareness.
Pain disorder is commonly associated with anxiety and depression. It is also associated with substance abuse and personality disorders.
There are a number of specific syndromes that are considered to be due to pain disorder. These include chronic headache, atypical facial pain, non specific back pain, chronic pelvic pain, non cardiac chest pain and non specific abdominal pain.
Amended May 2009
