CONVERSION

DISORDERS
(FUNCTIONAL
NEUROLOGICAL
SYMPTOM DISORDER)
◻ Many people frequently visit the doctor even when there is
no physical illness present. These individuals may have an
intense focus on their health and bodily sensations, which, in
some cases, becomes so extreme that it disrupts their daily
functioning. The term "soma" refers to the body, and in
somatic disorders, the primary issue often appears to be
physical. However, there is usually no identifiable physical
cause for their symptoms. The DSM-5 outlines five main
somatic symptom and related disorders: somatic symptom
disorder, illness anxiety disorder, psychological factors
affecting medical conditions, conversion disorder, and
factitious disorder. In each disorder, individuals experience
an excessive and maladaptive concern with their body's
functioning.
SOMATIC SYMPTOM AND
RELATED DISORDERS
◻ In the DSM 5 (APA, 2013), there are five major
somatic symptoms and related disorders. These
disorders fall under this umbrella as they have a
common thread of preoccupation with bodily functions
or appearance. Excessive, maladaptive responses to
physical symptoms or health concerns to the extent of
functional impairment are also a significant feature.
◻ They are a group of psychological conditions where a
person experiences intense physical symptoms that
cause significant distress or disrupt their daily life,
without any identifiable medical cause.
•Somatic symptom and related disorders
•Somatic Symptom Disorder
•Illness anxiety disorder
•Conversion Disorder
•Psychological factors affecting medical condition
•Factitious Disorder
 Somatic Symptom Disorder
◻ Somatic Symptom Disorder, initially named Briquet's syndrome after the
French physician who observed that some patients reported numerous
physical complaints without any medical basis (APA, 1980), is now
defined in the DSM-5 as involving significant distress, persistent worry,
and excessive focus on one or more physical health concerns lasting over
six months. This preoccupation is often disproportionate and involves
considerable time and resources spent on monitoring health. Depending on
the variety and number of somatic complaints, as well as the intensity of
preoccupation, clinicians can specify the severity of the condition in the
diagnosis. If the primary complaint involves pain, this too can be
specifically noted.
◻ Another example of Somatic Symptom Disorder is persistent pain, where
the experience and intensity of pain are maintained or even worsened by
psychological factors, regardless of any identifiable physical cause.
Previously diagnosed as pain disorder, the primary issue in Somatic
Symptom Disorder is not the presence or absence of a physical cause but
rather the psychological impact, such as distress, anxiety, and
preoccupation with health concerns (Henningsen, 2018).
Case Example
◻ Suresh, an office worker in his 30’s reported that he has
been experiencing considerable backache in the last few
months. He added that he has had a number of similar
problems in the last few years but no one could clearly
diagnose the reasons for them. He has been to a number
of hospitals and has been on a variety of medication,
but has not had any length of time when he felt healthy.
He was extremely distressed by his recurring pain that
were also making it difficult for him to perform
adequately at work. He would either spend most of his
time worrying about his health while in the office or he
would take days off to seek help and recover
 Illness Anxiety Disorder
◻ Illness anxiety disorder (previously known as
hypochondriasis) is a condition in which physical symptoms
are either not experienced at the present time or are very
mild. However, the accompanying anxiety focused on the
possibility of developing a serious disease/s is excessive.
◻ Illness anxiety disorder is differentiated from somatic
symptom disorder, in that the physical symptom experienced
is mild. In case the physical symptoms are severe and are
associated with anxiety and distress, the diagnosis would be
somatic symptom disorder.
◻ Formerly known as “hypochondriasis”, illness anxiety
disorder is characterised by excessive concern with the
possibility or idea of being sick. This is in contrast to the
previously discussed diagnosis where the preoccupation is
with the physical symptoms.
Case Example
◻ Rishi is a 45-year-old male engineer presents to a neurologist with
multiple internet searches on the topic of cancer. He states that he
“just knows” that he has a brain cancer. When asked how long this
concern has bothered him, he says “for years I have been thinking
that I have tumour growing in my head.” When asked about
relevant symptoms, he is a bit vague, saying “I get some pain or
pressure right here (he points to the left side of his head) but it is
not there all the time.” Upon asking about his previous visits to
doctors, he replies, “I have had some tests done, MRI and CT scan
but the doctors could not find anything.” He admits to feeling
relieved after the results, but then few weeks later he was restless
again, “they must have just missed something,I think I need
another MRI.”Rishi is anxious and increasingly irritable when the
doctor tells him that since he had recently got most of the tests
done and there was no need for another MRI scan. Rishi ends the
encounter by stating that he will “find another doctor who sees my
point and will get me what I need.”
◻ Rishi is a typical case of Illness Anxiety Disorder, where his primary concern is
a preoccupation with the idea of having brain cancer, even when his
symptoms—like a mild headache—are absent or minimal.
◻ People with Illness Anxiety Disorder are often highly focused on normal bodily
functions, such as heartbeat, digestion, blood pressure, or on minor symptoms
like coughs, joint pain, or vague sensations (e.g., "aching veins" or "my heart
feels tired"). They remain on constant alert for any new symptoms and are often
preoccupied with digestive and excretory functions. Though their descriptions
may lack medical precision, they often provide detailed accounts to help the
doctor "find" a diagnosis, even when no actual illness exists. Some may
meticulously track their symptoms, keeping records of bowel movements, diet,
or other health details. They tend to stay informed on medical topics and may
believe they have every disease they read about. Many use over-the-counter
medicines frequently, though they are not consciously faking symptoms
(malingering).
◻ Those with a "care-seeking" type of Illness Anxiety Disorder may visit a mental
health professional only after multiple consultations with general physicians.
 Conversion Disorder
◻ Sigmund Freud popularized the term conversion (conversion hysteria) who
believed that the anxiety resulting from unconscious conflicts was “converted” into
physical symptoms which allowed individuals to release some anxiety without
experiencing it.
◻ In DSM-5, conversion disorder is given the subtitle ‘Functional Neurological
Symptom Disorder’. Functional Neurological Symptom refers to symptoms that
result in absence of an organic cause. Most conversion symptoms suggest that some
kind of neurological disease is affecting the sensory-motor systems, but no organic
or physical malfunctioning is present. Conversion disorder is one of the most
fascinating of all mental disorders.
◻ Conversion Disorder is identified by the presence of neurological-like symptoms
without an actual neurological diagnosis (Feinstein, 2011). This means the patient
experiences sensory or motor deficits that resemble a medical or neurological
condition. However, the pattern of these symptoms does not align with any known
neurological or medical issue.
◻ Common examples include partial paralysis, blindness, deafness, and episodes of
limb shaking with loss of consciousness, resembling seizures. Importantly, this
diagnosis is only made after a thorough medical and neurological evaluation. It
should also be noted that individuals are not deliberately creating or faking their
symptoms. Instead, psychological factors are often considered significant
contributors, as the symptoms typically begin or worsen in response to emotional or
interpersonal conflicts or stress, as illustrated in the following case example.
Why Functional?
◻ The condition you're describing is now referred to as Functional
Neurological Symptom Disorder (FNSD) in the DSM-5, replacing the
older term "Conversion Disorder." This update reflects a shift away from
psychoanalytic connotations, where "conversion" historically implied that
psychological conflicts were being "converted" into physical symptoms.
◻ Individuals with FNSD experience neurological symptoms—such as
motor or sensory impairments—without an identifiable medical or
neurological cause. Symptoms can include weakness, paralysis, abnormal
gait, tremors, or sensory loss, and often resemble conditions like stroke,
epilepsy, or other neurological disorders. However, unlike other
neurological diagnoses, FNSD lacks an underlying organic basis, leading
to its classification as a "functional" disorder.
◻ The reclassification and terminology update aim to reduce the stigma and
clarify that the symptoms are genuine and distressing for the patient, even
though they don't stem from a detectable physical cause. This approach
also encourages clinicians to focus on symptom management and
rehabilitation rather than solely investigating for organic causes.
 Difficulty in Diagnosis
◻ One of the complexities in diagnosing Conversion Disorder, or Functional
Neurological Symptom Disorder (FNSD), lies in differentiating genuine
conversion symptoms from those that could stem from an undiagnosed
physical disorder—or even from intentional fabrication, known as
malingering. Historically, an attitude of "La belle indifférence"—a noticeable
lack of concern about one's symptoms—was seen as a hallmark of conversion
disorder. However, later studies, such as those by Stone et al. (2006), revealed
that indifference toward symptoms can also occur in individuals with genuine
physical disorders, making it an unreliable diagnostic criterion.
◻ Accurate diagnosis often involves examining factors such as the presence of
recent stressors that may have triggered the symptoms, the sudden onset or
remission of symptoms, and paradoxical behaviors—such as a reported
inability to see, despite responding to visual stimuli, like avoiding obstacles.
◻ These indicators can help differentiate conversion disorder from malingering,
where symptoms are consciously faked, usually for personal gain. Malingerers
are typically aware of their actions and may simulate symptoms to manipulate
others or secure external benefits, such as financial compensation or avoiding
responsibilities. In contrast, individuals with conversion disorder experience
real and involuntary symptoms, often without awareness of their
psychological origins.
 Case Example 1
◻ 23-year-old Naina was brought to the emergency department of a hospital. She
reported “suddenly passing out for a couple of seconds at work.” She stated that she
woke up with blurred vision that developed into loss of vision in both eyes. She also
reported an inability to stand due to weakness in her left leg. While in the emergency
department, the patient described seeing only shadows. She stated that she was
generally in good health without significant medical issues or any history of chronic
medical conditions or surgeries, which was confirmed by her mother. She had no
reported mental health history and no history of stressful childhood experiences (i.e.,
abuse or neglect). Naina’s mother reported that her daughter was in a lot of stress since
the last couple of years. Her parents got her married right after graduation. She wanted
to study more but at that time her parents did not encourage. Her marriage turned out
to be extremely stressful as her husband would often get drunk and become abusive
towards her. She left her husband’s home one year after marriage and came back to
live with her parent. After facing significant financial difficulties, Naina finally found
a job, but her difficulties were far from over. Her husband sent her a divorce notice and
she recently found out that she was pregnant. On physical examination, the patient was
alert, awake, and oriented to person, time, and place. On neurological examination, her
speech was normal, her pupils were slightly sluggish but reactive, she was able to see
light that was shined into her eyes, and she demonstrated a full range of eye
movement, but there was no visual insight to hand motion or finger counts. She had
some trouble lifting her left leg off the bed but was able to walk with assistance. All
tests came to be normal.
 Case Example 2
◻ Sana, a 15-year-old high school student was admitted to a general
hospital with flu-like symptoms which proceeded to persistent
vomiting and nausea. As investigations ruled out possibilities of any
infection, she was discharged from the hospital after 2 days with
medications to manage the symptoms of nausea and vomiting. In the
next few days her condition seemed to worsen with her legs starting
to feel weak even if she was standing for a few minutes. She was
then evaluated by other specialists such as cardiologists and no
organic causes were notable for her symptoms. Over the next 2
weeks her symptoms seemed to grow into numbness of legs and
being unable to get up or stand without aid. She was then referred to
a neurologist. While no biological causes for her symptoms were
found, it was noted that she grew up with her father being physically
abusive towards her and her mother until the age of 13 years, when
her mother divorced her father and they moved to a new city. A few
months later they moved again to live with her maternal
grandparents and had to switch to a new city, school and living
environment.
Clinical Picture
◻ Another disorder within the diagnostic category of somatic
symptom and related disorders is conversion disorder. The term
conversion disorder is relatively recent. Historically this disorder
was one of several disorders that were grouped together under the
term hysteria.
◻ Individuals with Conversion Disorder exhibit symptoms that
impair sensory or voluntary motor functions, often resembling a
neurological condition.
◻ To diagnose Conversion Disorder accurately, it is essential to rule
out any medical causes for these symptoms. Clinicians must
present clear evidence to differentiate between the symptoms of
Conversion Disorder and an actual neurological condition. This
distinction is crucial to avoid mistakenly diagnosing a real
neurological disorder as Conversion Disorder. Thanks to
advancements in medical technology, the rate of misdiagnosis for
Conversion Disorder has significantly decreased compared to the
past.
◻ Sensory deficits in Conversion Disorder include phenomena like
conversion blindness, as shown in the case study. In such cases, a person
may report being unable to see anything but can still navigate a room
without bumping into objects. Similarly, someone with conversion
deafness might claim to be unable to hear but will still respond when their
name is called. This indicates that sensory input is registered but somehow
prevented from reaching conscious awareness. Other sensory symptoms
include anesthesia (loss of sensitivity), hypoesthesia (partial sensitivity
loss), hyperesthesia (excessive sensitivity), analgesia (loss of pain
sensitivity), and paresthesia (unusual sensations like tingling or warmth).
◻ Common motor symptoms include conversion paralysis, where a person is
typically unable to walk but may temporarily regain mobility in
emergencies, such as escaping a fire. Other motor symptoms include
tremors, tics, and contractures (joint stiffness). Astasia-abasia, a condition
where a person has an uncoordinated, erratic walk with wobbling legs, is
also noted. Speech-related symptoms include aphonia, where the
individual can only speak in whispers or a hoarse voice.
◻ Conversion seizures, or pseudo-seizures, mimic
epileptic seizures but lack EEG abnormalities and
don't result in confusion or memory loss afterward.
People experiencing conversion seizures rarely
injure themselves in falls or lose control over
bodily functions. Other medically unexplained
symptoms include sensations of a lump in the
throat, choking, coughing fits, difficulty breathing,
nausea, and vomiting. There have even been cases
reported of conversion reactions mimicking
malaria, tuberculosis, and pseudo-pregnancies
Range of Symptoms
◻ Conversion disorder symptoms can be categorized into four main types,
each with unique features that mimic physical ailments but lack a medical
basis. These categories are:
◻ 1. Sensory Symptoms or Deficits
◻ Description: Conversion disorder can affect various sensory modalities,
such as vision, hearing, and touch.
◻ Examples:
Visual disturbances: Individuals may report blindness or tunnel vision but
still navigate around obstacles without difficulty, suggesting that some sensory
information is being processed unconsciously.
Auditory issues: Conversion deafness may occur, where the individual reports
being unable to hear, but they may still respond to sounds like their name.
Anesthesia: Loss of sensation in a specific body part, such as "glove
anesthesia," where sensation is absent in the hand as though a glove were
blocking feeling, despite no anatomical reason.
◻ Underlying Mechanism: Sensory input is likely processed but not
consciously recognized, resulting in a functional sensory deficit.
◻ 2. Motor Symptoms or Deficits
◻ Description: Motor symptoms in conversion disorder can range
widely, involving paralysis, abnormal movements, or speech
issues.
◻ Examples:
Paralysis: Often affects a single limb, like an arm or a leg, and is
selective for certain activities; for example, a person may be unable
to write but can use the same muscles for other tasks.
Gait disturbances: The person might report an inability to walk,
but in emergencies, such as a fire, they might move normally.
Speech issues: Aphonia, where the person can only whisper but can
cough normally, is a common symptom. This is distinct from true
paralysis of the vocal cords.
Globus: A sensation of a lump in the throat that is psychologically
induced rather than physically present.
◻ 3. Seizure-like Symptoms
◻ Description: Individuals may experience seizures that resemble
epilepsy, but these are not true epileptic events.
◻ Examples:
Characteristics: Conversion seizures often involve dramatic
movements, thrashing, or writhing that are not typically seen in
epileptic seizures.
Distinguishing Features: Unlike true seizures, conversion seizures do
not show EEG abnormalities, and patients rarely lose control of bowel
or bladder functions, nor do they experience confusion or memory loss
afterward.
◻ Distinction from Epilepsy: Conversion seizures are typically less
injurious, lack consistent neurological markers, and often differ in
presentation.
◻ 4. Mixed Presentation
◻ Description: Some cases of conversion disorder
present with a combination of sensory, motor, and
seizure-like symptoms, making the diagnosis more
complex.
◻ Examples: A person may experience paralysis in
one limb along with loss of vision in one eye or an
inability to hear certain sounds, combining
symptoms from multiple categories.
Prevalence rate
◻ The lifetime prevalence is not known with certainty, highest
estimates is 0.005 percent (APA, 2013). Women outnumber
the diagnoses of conversion symptoms by a ratio of 2:1 to
10:1; people from low socio-economic strata are more likely
to develop conversion symptoms (Encyclopaedia of Mental
Disorders, 2015) Conversion symptoms may appear at any
time but most people experience their first symptoms during
adolescence or early adult years. Onset is abrupt and
typically follows a major stressor. The course of the disorder
may either be episodic or chronic. In a subsequent episode,
the conversion symptom may be different from the
symptom(s) in the previous episode. Comorbid anxiety and
mood disorders are also common. Conversion disorder is at
least 2-3 times more common in women.
 Causes
◻ Initially, genetic factors were thought to play a role in the causation
of conversion disorder; however, twin studies did not provide
evidence for this link, indicating a stronger influence of psychosocial
factors.
◻ Psychoanalytic Theory: Freud developed a model of conversion
disorder through his treatment of the well-known case of Anna O,
first documented in Studies on Hysteria (Freud and Breuer, 1895).
He proposed four main processes in the development of conversion
disorder:
◻ The individual encounters an unconscious conflict.
◻ This conflict and the resulting anxiety are repressed due to their
unacceptable nature.
◻ As the anxiety builds, it threatens to surface consciously, prompting
the person to use defense mechanisms that “convert” the conflict into
physical symptoms, thus reducing anxiety—a primary objective of
the process.
Continued..
◻ The individual then gains increased attention and sympathy from
loved ones, possibly avoiding certain unwelcome responsibilities
as well.
◻ Freud’s explanation has found empirical support, with research
indicating that individuals with conversion disorder often
experienced traumatic events from which they sought escape. For
example, during wartime, soldiers would sometimes exhibit
symptoms like leg paralysis as a way to avoid the traumatic
experiences of combat without facing accusations of cowardice.
Another study showed that many patients with conversion disorder
had histories of traumatic experiences, such as sexual abuse,
parental divorce or death, or physical abuse. Evidence of
"secondary gain" is seen in findings that adolescents with
conversion symptoms often described their mothers as
"overinvolved" or "overprotective," suggesting that their
symptoms received significant attention and reinforcement.
◻ Socio-cultural Perspective: Over the last century, the
incidence of conversion disorder has visibly declined,
pointing to a potential influence of socio-cultural factors. In
Western countries like the United States and England,
diagnoses of conversion disorder have decreased, while the
disorder remains more prevalent in nations like Libya,
China, and India, where there may be less focus on
understanding distress through psychological frameworks.
◻ Conversion symptoms are also more frequently reported in
rural areas, where access to medical knowledge is limited.
Increased medical knowledge and greater awareness of the
defensive role of conversion symptoms are thought to be key
factors behind the reduced occurrence of conversion
disorder.
Treatment
◻ People with conversion disorder often respond well to
cognitive-behavioral therapy (CBT). A key initial step in treating
conversion disorder is identifying any traumatic or stressful life
events, which may either be real or retained in the individual’s
memory. For example, in Naina’s case (Box 6.5), the distress
stemmed from an abusive relationship with her husband, a pending
divorce, and the discovery of her pregnancy. The next step
involves educating the family about the impact of secondary
reinforcements like attention and sympathy. Naina’s family, for
instance, was advised not to reinforce her conversion symptoms
with excessive attention; instead, her mother was encouraged not
to restrict Naina’s mobility due to her conversion blindness and to
support her in gradually resuming daily activities with assistance
from family members.
PSYCHOLOGICAL FACTORS AFFECTING
MEDICAL CONDITION

◻ The essential feature of this disorder is that an individual has a diagnosed

medical condition (e.g. asthma, diabetes, hypertension etc.) that is
adversely affected by one or more psychological or behavioural factors.
◻ In this condition, the psychological or behavioural factors have a direct
influence on the diagnosed medical condition either by triggering or
worsening the medical condition, interfering with treatment or
contributing to death or disability.
◻ In such cases, psychological distress, anxiety, depression, personality
traits, and relationship issues place an additional strain on the individual's
ability to manage their health. For instance, stress or depressive symptoms
might make a person more likely to avoid health-preserving behaviors,
ignore early symptoms, or resist following a doctor’s advice.
◻ One example would be a patient with diabetes who is in denial about the
need to take medication to control her/his sugar levels. Another example
would be a skin cancer survivor who routinely forgets to apply sunscreen
cream to protect herself/himself.
◻ Addressing these psychological factors is essential, as they directly affect
both the individual's motivation and capacity for self-care, potentially
impacting the progression and severity of their medical conditions.
 FACTITIOUS DISORDER
◻ The core feature of factitious disorder is the falsification of medical or
psychological signs or symptoms in the absence of obvious external
rewards, such as financial gain or work leave.
◻ A disorder that shares features of both malingering and conversion
disorder.
◻ Unlike malingering, where the motive is usually obvious, the reasons
behind symptom fabrication in factitious disorder are often unclear. In
some cases, the primary motivation appears to be the desire to adopt the
“sick role” and gain attention.
◻ For example, a woman might introduce alkaline chemicals into her eyes to
cause corneal burns before visiting an eye specialist, or a man might
complain of severe abdominal pain and demand an appendix removal,
later self-inflicting a stomach abscess with a kitchen knife when denied
surgery. A diagnosis of factitious disorder requires confirmation that
symptoms are self-induced.
◻ This disorder can also involve others, as in factitious disorder imposed on
another, where a caregiver, often a parent, deliberately makes a child ill to
gain sympathy and attention as the caretaker of a sick child.
Distinguishing Between Conversion Disorder,
Factitious Disorder, and Malingering (Faking)
◻ Individuals with conversion disorder may show surprising abilities, such
as a person with conversion blindness not colliding with objects, or
someone with conversion deafness orienting toward sounds. In
emergencies, those with conversion paralysis might suddenly regain
mobility, as seen in “miraculous” cures during religious events, which
could indicate conversion disorder. Accurate diagnosis requires ruling out
genuine neurological conditions, and technological advances have
reduced misdiagnosis rates over time.
◻ Distinguishing between conversion disorder and malingering can be
challenging. Malingerers have clear motives, such as avoiding legal or
work obligations or gaining financial benefits, and they are fully aware of
their deception, manipulating others to achieve these goals.
◻ Factitious disorder, on the other hand, falls between malingering and
conversion disorder. While symptoms are intentionally produced, there is
no clear incentive, except perhaps to adopt the “sick role” and receive
attention. Unlike malingerers, those with factitious disorder are not
motivated by external rewards but rather by the desire to be seen as ill.
Summary
◻ Somatic Symptom Disorder (SSD)
◻ Key Feature: Excessive focus on physical symptoms
(e.g., pain, fatigue) that are distressing and disrupt daily
life.
◻ Symptoms: Symptoms are real to the patient and may
or may not have a medical basis.
◻ Psychological Impact: High levels of anxiety about
health and physical symptoms; often extensive medical
consultation with limited reassurance.
◻ Duration: Symptoms are persistent, often lasting more
than six months.
◻ 2. Illness Anxiety Disorder (Hypochondriasis)
◻ Key Feature: Persistent worry about having a serious illness despite few or no
physical symptoms.
◻ Symptoms: Often minor or mild, but the patient is excessively preoccupied with
having a severe medical condition.
◻ Psychological Impact: Extreme health anxiety and reassurance-seeking behaviors;
frequent doctor visits but rarely satisfied with medical explanations.
◻ Duration: Anxiety about health persists for at least six months, even if symptoms
change.
◻ 3. Conversion Disorder (Functional Neurological Symptom Disorder)
◻ Key Feature: Neurological symptoms (e.g., paralysis, blindness) that are
inconsistent with or unexplained by medical conditions.
◻ Symptoms: Sensory or motor dysfunction (e.g., seizures, paralysis, loss of
sensation) with no physical basis.
◻ Psychological Impact: Often linked to psychological stress or trauma, though the
patient may not connect the symptoms to these factors.
◻ Awareness: Symptoms are involuntary, and the individual genuinely believes they
are real.
4. Factitious Disorder
◻ Key Feature: Deliberate production or falsification of
symptoms without clear external incentives (often for
attention or sympathy).
◻ Symptoms: Self-induced or exaggerated physical or
psychological symptoms.
◻ Psychological Impact: Strong need for the “sick role” and
may go to great lengths to maintain it, often with concealed
intentions.
◻ Awareness: Symptoms are consciously fabricated, but
motivation is often subconscious (e.g., need for care or
sympathy).
◻ 5. Psychological Factors Affecting Other Medical
Conditions
◻ Key Feature: A diagnosed medical condition is
worsened by psychological or behavioral factors.
◻ Symptoms: Psychological stress or behaviors (e.g.,
neglecting treatment) worsen an existing medical
condition.
◻ Psychological Impact: Behaviors like denial or poor
adherence to medical advice impact health negatively.
◻ Awareness: Patient may or may not recognize the
impact of their psychological state or behaviors on the
condition.