Clinical Setting - Conversion Disorder and Somatoform Disorder Not Otherwise Specified

Patients with acute conversion symptoms tend to present to emergency departments of hospitals. Rapid and accurate diagnosis of the disorder is important to effect symptom relief and to rule out concurrent physical or psychological disorders. These acute symptoms are frequently accompanied by intense anxiety in the patient and accompanying family members or friends. The symptoms may dramatically remit with an appropriate suggestion, hypnosis, or an amobarbital-assisted interview (Hamilton 1981). However, it must be emphasized that dramatic remission of even a nonphysiological symptom does not rule out the possibility of significant underlying neurological disease (Fishbain and Goldberg 1991; Gould et al. 1986). Thus, it is essential that adequate follow-up care be arranged for a diagnostic medical-neurological evaluation and psychiatric treatment (Hamilton 1981). Care must be taken that multiple examinations by different or inexperienced examiners do not reinforce the symptom (Sim 1982).

Precipitating stressors play a particularly important role in patients with acute conversion, and they may be even more apparent in the emergent situation. However, the realities of an emergency department, particularly late at night, are that treatment resources are limited and referrals to other physicians for follow-up care are generally indicated. Unfortunately, in the transfer of care, much of the understanding gained from the acute initial evaluation can be lost. Careful descriptive records are invaluable.

One role of the emergency service is to determine those patients who require inpatient medical-neurological or psychiatric hospitalization. When the extent of the patient's physical disease is uncertain, he or she may do best in a nonpsychiatric setting. Patients whose symptoms may represent a defense against suicidal or homicidal impulses are best cared for on a psychiatric unit. Patients who developed symptoms secondary to environmental trauma may need supportive or protective hospitalization.

Patients with a conversion symptom who are referred to tertiary care centers (e.g., rehabilitation centers) or "superspecialists," in contrast to the emergency setting, usually are not considered acutely ill. With time, the perpetuation of the symptom, and the resultant psychological regression, these patients often present a different clinical picture. They generally show less anxiety, and issues associated with secondary gain are more dominant. Resistance to treatment is common, and any hint of psychogenicity is rejected by the patient and often the family. In fact, the patient's symptoms may have become a focal point of mutual concern, allowing displacement away from other family conflicts. Treatment must be less focused on the precipitating stressor and directed more toward the reinforcing behaviors of the patient, family, and environment (Toone 1990). Behavioral modification techniques, often in conjunction with physical therapy, are important treatment modalities. It is important to obtain all prior medical records because the patient's history may have been "revised" with the passage of time.