This presentation gives a brief outlook about psycho somatic medicine, conversion disorder and its common presentations.

1. PSYCHO SOMATIC
ILLNESSES
DR.V.MURUGAVEL
SENIOR RESIDENT
ESIC MEDICAL COLLEGE AND HOSPITAL
KK NAGAR CHENNAI

2.  Psycho- mind
 Soma- Body
 Deals with the relationship between mind and body, how this contributes to
illness
 Disorders of mind presenting with bodily symptoms
 e.g. Anxiety causing headache, chest discomfort
 Disorders of body presenting with psychological symptoms
 e.g. Acute Myocardial infarction causing fear of death

3. Mind Body

4. Occurrence of
Physical symptoms
in a patient with
no reasonable
medical
explanation

5. DISSOCIATIVE/CONVERSIO
N DISORDER

6.  It is defined as a psychiatric illness in which symptoms and
signs affecting voluntary motor or sensory function cannot
be explained by a neurological or general medical
condition.
 The term conversion disorder was coined by Sigmund
Freud
 Latest nomenclature is “Functional neurological symptom
disorder”.

7. Underlying
conflict
Psychological
distress
Neurological
symptom

8. HYSTERIA (Hippocrates)
CONVERSION (Sigmund Freud)
FUNCTIONAL NEUROLOGICAL
SYMPTOM DISORDER

9.  ICD 10 classifies conversion disorder as
CONVERSION
Motor
symptom
Sensory
symptom
Seizures Mixed

10. Common examples of conversion symptoms include
 blindness,
 paralysis,
 dystonia,
 psychogenic non-epileptic seizures (PNES),
 anaesthesia,
 swallowing difficulties,
 motor tics,
 difficulty walking,
 Hallucinations and
 dementia.

11. Who develop conversion?
 Women >> men 10:1
 Lower socio economic status
 Lack of education
 Developing countries
 20-25% of patients in a general hospital have conversion symptoms, around 5%
of patients in a hospital can be diagnosed with conversion disorder.

12. Why conversion
occurs?
 Biological factors that may characterize conversion disorder include
1. impaired cerebral hemispheric communication,
2. excessive cortical arousal that inhibits the individual's awareness of bodily sensations, and
3. possibly subtle impairments on neuropsychological tests.

13. Why conversion occurs?

14. Clinical features
1. A debilitating illness that begins suddenly
2. History of psychological problems
3. Symbolic relationship to the unconscious conflict
4. Lack of concern that usually appears with a severe physical symptom (La
belle indifference)

15. The term ‘gain’ is used to denote subconscious psychological
motivation of the patient when they present with symptoms.
S.N
O
PRIMARY GAIN SECONDARY GAIN TERTIARY GAIN
Positive internal motivations, no external
reward/escape from punishment
External motivators like money,
subsidies involved.
benefit that a third-party
receives from the patient's
symptoms
E.g Conversion disorder
A patient might feel guilty about being
unable to perform some task. If a medical
condition justifying an inability is
present, it may lead to decreased
psychological stress.
Malingering
An individual having household
chores completed by someone else
because they have stomach
cramps would be a secondary gain.
A pharmaceutical company
runs advertisements to
convince viewers they have
symptoms which require
treatment with the
company's drug.

16. How to differentiate from a classical
neurological syndrome?
S.NO PRESENTING
COMPLAINT
DIFFERENCES
1 BLINDNESS In conversion disorder, the patient, though complaining of recent onset of
blindness, neither sustains injury while maneuvering around the office nor displays
any expected bruises or scrapes. The pupillary reflex is present, thus
demonstrating the intactness of the optic nerve, chiasm, tract, lateral geniculate
body, and mesencephalon.
2 PARALYSIS In conversion paralysis, the patient loses the use of half of his or her body or of a
single limb, but the paralysis does not follow anatomical patterns and is often
inconsistent upon repeat examination.
3 APHONIA Conversion aphonia may be suspected when the patient is asked to cough, for
example, during auscultation of the lungs. In contrast with other aphonias, the
cough is normally full and loud.

17. S.NO PRESENTING
COMPLAINT
DIFFERENCES
4 PSYCHOGENIC
SEIZURES
Patients with psychogenic nonepileptic seizures generally lack response to
treatment with antiepileptic drugs or have a paradoxical increase in seizures
with antiepileptic drug treatment. The negative history of injury or loss of
control of bladder or bowel during the seizure episode is also significant.
5 PARAPLEGIA In conversion paraplegia, one finds normal, rather than increased, deep
tendon reflexes, and the Babinski sign is absent. In doubtful cases, the issue
may be resolved by demonstrating normal motor evoked potentials.
6 TREMORS When weights are added to the affected limb, patients with functional tremor
tend to have greater tremor amplitude, whereas in those with organic tremor,
the tremor amplitude tends to diminish.
7 SYNCOPE The conversion patient may report feeling faint or fainting, but no autonomic
changes are identified, such as pallor, and there is no associated injury. In
addition, the fainting spells have a “swooning” character to them, heightening
the drama of these events.

18. Prognosis is usually good
In patients where conversion disorder had a
1. sudden onset,
2. short duration,
3. an early identifiable stressor,
4. no ongoing litigation,
5. good premorbid functioning, and
6. lack of comorbid psychiatric disorders.

19. Treatment
1. Psychoeducation (address issues like knowledge, perception and attitude
towards illness)
2. Stress management
3. Treat underlying psychiatric disorders if any

20. SOMATISATION
DISORDER
DISSOCIATIVE
DISORDER
FACTITIOUS
DISORDER
MALINGERING
UNCONSCIOUS
CONFLICT
YES YES NO NO
SYMPTOMS
PRODUCED
VOLUNTARILY
NO NO YES YES
PRIMARY
GAIN(ESCAPE/REWA
RD)
NO NO NO YES
SECONDARY GAIN
(NEED FOR MEDICAL
ATTENTION)
NO NO YES NO
MOTIVATION TO GET TESTED &
DIAGNOSED
NO ADMISSION IS
ENOUGH
CERTIFICATE THAT
HE/SHE IS ILL
PSYCHIATRIC
DISORDER
YES YES YES NO
EXAMPLE Repeated scans for body
pain
Sudden loss of limb
function
Excess thyroxine taken to
present with tremors,
wants admission
Wants
admission/certificate that
he/she is ill.