Daily Archives: August 28, 2010

Comparing Conversion Disorder to Dissociative Disorders


Conversion disorder falls within the broader category of somatoform disorders in the DSM-IV-TR (2000).  Essential features include one or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological condition, accompanied by psychological factors judged to exacerbate or initiate the onset.  The symptoms are not intentionally produced (as in Factitious Disorder of Malingering), nor can they be fully explained by a general medical condition.  Typically someone diagnosed with Conversion Disorder will present with motor deficit (paralysis), sensory deficit (deaf, blind), seizures/convulsions, or some combination of the above (mixed).  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 498)

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“The essential feature of the dissociative disorders is a disruption in the usually integrated functions of consciousness, memory, identity, or perception.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 519)  This may manifest in an inability to recall information in dissociative amnesia, or the presence of two or more distinct identities in dissociative identity disorder (DID, formerly Multiple Personality Disorder or MPD).  It may also present as a recurrent feeling of being detached from one’s body or mental processes, as in depersonalization disorder.

Dissociative and conversion disorders share symptoms, may have similar antecedents (high rates of trauma), and both suggest neurological dysfunction.  “If both conversion and dissociative symptoms occur in the same individual (which is common), both diagnoses should be made.”  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 497)  Conversion disorder is classified as a dissociative disorder in the IDC-10.  In a recent and comprehensive comparison of the two disorders, Brown and associates have strongly suggested that “moving pseudo-neurological symptoms (i.e., conversion disorder) back to the dissociative fold would make better sense of the empirical database, help conceptual integration of related areas, and, last but not least, finally bring concordance across DSM and ICD taxonomies.”  (Brown, Cardeña, Nijenhuis, Sar, & van der Hart, 2007, expression CONCLUSIONS AND IMPLICATIONS)  Despite differences in presentation (outlined above), I inclined to agree with proponents of including conversion disorder as part dissociative disorders in the DSM-V.

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Brown, R. J., Cardeña, E., Nijenhuis, E., Sar, V., & Van der Hart, O. (2007, Sep/Oct). Should conversion disorder be reclassified as a dissociative disorder in DSM-V. Psychosomatics, 48(5), 369-379. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1333420861&sid=4&Fmt=4&clientId=4683&RQT=309&VName=PQD

Factitious Disorders | Factitious Disorder by Proxy | Munchausen Syndrome


Factitious Disorders and Factitious Disorder by Proxy covers the disorders formerly known as Munchausen Syndrome.  By definition, factitious disorders are a condition in which symptoms are feigned or created by the patient.  This might manifest in by someone complaining about a pain that doesn’t exist, or it might result in the client drinking a pint of Drain-o to get sick.  Generally speaking, the goal or objective is to assume the “sick role,” and subsequently obtain the benefits that are generally imbued on them as a result.

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Do kids start lying as early as age 2?  It would appear that they learn to lie about the same time they learn how to talk.

“As children, many of these patients experienced rejection, mistreatment, and parental loss.  For them, the hospital provides a haven or refuge.”  (Netherton, Holmes, & Walker, 1999, p. 305-306)  I have trouble identifying with this… you couldn’t pay me to go to a hospital; I avoid them like I avoid the plague.  I don’t know if most “normal” people feel like that, but it’s about the last place I would consider a refuge…

Factitious disorders are best differentiated from malingering by accessing the goal.  “Only when the sick role becomes part of the child’s life can the diagnosis of factitious disorder be considered.”  (Netherton et al., 1999, p. 306)  So, factitious disorders represent more than malingering in a sense that they are persistent efforts to appear sick, without any apparent short term goal other than to obtain the sick role status.  If that means the client has to lie, they often do.  The symptoms are intentionally produced, and the patient can voluntarily make them appear or disappear.  In that respect, they differ from somatoform disorders because they are voluntary, not involuntary.  Where malingerers pretend to be sick, somatoform sufferers feel doomed to be sick, and sufferers of factitious disorder creating symptoms that to ensure that status.  (Netherton et al., 1999, p. 307)

Treatment begins with confrontation.  A “normal” person (I am not sure I can ever write the word normal again without the “”) would probably stop lying right there and the problem would be solved.  Unfortunately, that confrontation does not typically resolve the issue with factitious disorders.  I was surprised to see that the relationship typically improves after that process occurs though… I wonder if there is a sense of relief on the part of the client that they have been caught.

The “by proxy” version of Factitious Disorder is fascinating.    Check out this video… I couldn’t believe my eyes! http://www.youtube.com/watch?v=UVLqADEdrig&feature=related People who suffer from this disorder make their kids sick, or engage in deceptive behavior to make them appear sick… ultimately in an effort to gain attention or sympathy.  The average time taken to uncover the proxy diagnosis was estimated to be 14.9 months!  (Netherton et al., 1999, p. 310)  Although the text makes a case for more widespread general knowledge, that process has unfortunately led to many false identifications and misdiagnosis.  One surefire way to identify the proxy diagnosis is to remove the child from the care of the parent or caregiver and see if their issues persist.  Another (more controversial, if that’s even possible) method is to covertly attempt to videotape the act of child abuse.  Imagine the legal ramifications if you were wrong!  It’s a pretty hefty gamble; we could potentially lose a license over a misdiagnosis like that.

How does mandatory reporting play into this “by proxy” diagnosis.  I mean, if you even suspect this as a possible diagnosis, don’t you have to report it?

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Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.