ReviewConversion Disorder: Current problems and potential solutions for DSM-5
Introduction
In this article we discuss the diagnostic criteria for Conversion Disorder as described in the DSM-IV-TR [1] from the perspective of psychiatry, neurology and psychology and offer potential solutions for its description and classification in DSM-5. The article is authored by members of, and advisors to, DSM-5 work groups on somatoform and dissociative disorders. Whilst the article reflects discussion and debate that has taken place in these groups, it is not an official position statement of the American Psychiatric Association. The article highlights areas of agreement but is also intended to stimulate further discussion and debate [2], [3], [4], [5] regarding those areas where there is no consensus. In particular we discuss the thorny problems of terminology, the limited diagnostic reliability that the current criteria allow, the question of whether psychological factors and exclusion of feigning should be part of the diagnostic criteria, the need for recognition of the positive signs of inconsistency and incongruity on which the diagnosis is currently made and where the problem should be located in the classification. The current Conversion Disorder criteria as defined in DSM-IV-TR are shown in Box 1.
Section snippets
What should we call Conversion Disorder?
Terms for symptoms unexplained by disease have to fulfil many functions [6]. The ideal term would be acceptable and usable to patients and doctors in a way that facilitates multidisciplinary treatment. Despite being in official nomenclature since 1935 [7], ‘conversion’ has not achieved the dominance as a term among clinicians and researchers that might have been hoped for. Survey research confirms that a wide variety of terminology is used between countries and neurologists, psychiatrists and
The requirement for the association of psychological factors
(CRITERION B: “Psychologic factors are judged to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit.”)
The “psychological association” criterion appears to us to be both theoretically and clinically problematic. Theoretically, the criterion has evolved from the conversion hypothesis. As with most psychiatric disorders, most but not all studies have found an excess of life events and prior emotional
Where should ‘conversion disorder’ be placed within the classification?
Significant changes are being proposed to the somatoform disorders by the DSM-5 committees. These changes involve not just relabeling somatoform disorders as somatic symptom disorders, but merging somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder [46] into a new category: “complex somatic symptom disorder” (CSSD) [47] (Box 2). Discussion of the consequence of such a change for conversion disorder was deferred in a recent preliminary report [47].
Is Conversion Disorder a homogeneous category?
Conversion symptoms have traditionally been grouped together because they have been considered qualitatively different from other somatic symptoms in the somatoform disorders group. However, conversion disorder currently includes a wide variety of symptoms such as blindness, movement disorder, paralysis and seizures. Some of these are paroxysmal, some intermittent and some are persistent. Some patients may have a single symptom and others multiple symptoms. In addition there are symptoms that
Conclusions
We propose the following changes to the DSM-IV category of conversion disorder be considered for DSM-5 (Box 3):
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The name should be changed. Conversion disorder is not a useful term for this group of symptoms. Functional Neurological Symptom Disorder, Dissociative Neurological Symptom Disorder and Psychogenic Neurological Symptom Disorder are possible alternatives.
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The current criteria B and C regarding psychological factors and feigning should be removed as essential diagnostic criteria but
Conflict of interest
JL and MS are members of the Somatic Symptom Disorders work group for DSM-5. JS, WCL are advisors to the Somatic Symptom Disorders work group for DSM-5. WCL is an advisor to the Dissociative Disorders work group for DSM-5. RB and DS are members of the Dissociative Disorders work group for DSM-5.
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