Review
Conversion Disorder: Current problems and potential solutions for DSM-5

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Abstract

Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label “conversion disorder” and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for “association of psychological factors” and the “exclusion of feigning” to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current ‘disease exclusion’ criteria to one in which the symptom must not be ‘better explained’ by a disease if present, (d) adding a ‘cognitive symptoms’ subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.

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):

  • 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.

  • 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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