Treatment Strategy - Conversion Disorder and Somatoform Disorder Not Otherwise Specified

Effective diagnosis and treatment of conversion disorder require a range of clinical assessments and skills. Among these skills are techniques of obtaining historical information that are key to understanding the patient's symptom. This includes the importance of having the patient describe, in detail, the immediate circumstances, including emotional state, for the onset of the symptom. Furthermore, the details of relationships with other persons who have experienced similar symptoms may provide important material about identification and conflicts. This type of clinical material may be of use in providing support and suggestion, particularly in the acute phase of conversion symptoms.

All five axes of DSM-IV are called into use to make comprehensive treatment interventions. The use of the "three P's"—predisposition, precipitating stressors, and perpetuating factors—is a shorthand way to conceptualize and formulate a treatment plan for each patient.

1. Predisposition includes consideration of 1) personality factors and past experiences that facilitate a tendency to somatize; 2) impaired communicative ability, including social prohibitions; and 3) underlying psychiatric or neurological disorders.

2. Precipitating stressors may include psychological conflicts (e.g., an impending marriage that raises issues of sexuality or separation from mother) or traumatic events (e.g., combat, sexual abuse).

3. Perpetuating factors include the presence of secondary gain and the degree to which the symptom resolves the original problem. In this respect, it is often difficult to distinguish primary from secondary gains. From a practical standpoint, this determination probably does not make much difference for most patients. For example, if a sexually conflicted and dependent woman develops a psychogenic paraplegia just before her wedding, the symptom may cause her to postpone or even cancel the wedding and simultaneously draw her closer to her parents, who provide dependent care. Primary and secondary gains become blurred when the symptom meets a need or is multidetermined.

The treatment strategy must encompass all three of the above components. Conversion must be viewed as a symptom, and the goal of effective treatment must be not merely symptom relief but also attention to the various factors that produced it. The patient must always be evaluated for the possibility of an underlying psychiatric or neurological disorder. The latter must be considered, even if the symptom itself is clearly nonphysiological, because of the frequent association of conversion symptoms with neurological dysfunction (Bowman 1998; Caplan and Nadelson 1980a; Merskey 1979; Whitlock 1967). Other predisposing factors that may require attention in the treatment plan include a present or past history of physical or sexual abuse and personality disorders (Bowman and Markand 1999; Griffith et al. 1998; LaBarbara and Dozier 1980; Merskey 1979; Wyllie et al. 1999).