Neurologic Evaluation of the Somatoform Patient: Somatoform Conversion Reactions

DIAGNOSIS

Pain behavior in the context of chronic pain has a wide differential diagnosis, requiring clinicians to incorporate historical and examination findings into an unbiased patient-centered global assessment. However, sensory findings, including midline pain/touch sensation splitting, vibration sense splitting, and inconsistencies in symptom reporting and examination responses on clinical examination, offer useful contexts for the clinician to carefully assess the role of psychosocial factors that may be contributing to reported pain intensity. Sometimes somatoform patients report an unequivocal sensory loss exactly to the midline for all sensory modalities. Testing of vibration perception is sometimes a good means to differentiate the organic from the somatoform patient. If the clinician places the tuning fork on a midline position, such as the skull or sternum, and then tilts the double end of the instrument to the “affected side,” the somatoform patient will report lack of any vibratory appreciation. In contrast, with the base unchanged and the fork then tilted to normal, this patient will appropriately report normal perception. However, the clinician evaluating such symptoms must recognize that certain painful symptom patterns related to a thalamic stroke or postherpetic neuralgia may precisely respect the midline.

The concept of la belle indifference, as it was initially described, also applied to patients who were unaware of sensory loss found on examination. The term has also been used to describe a certain indifference of patients to the symptoms they are presenting with; however, this finding performs poorly as a discriminator of organic disease.

TREATMENT

The biopsychosocial model of pain stresses the multitude of factors that influence a person’s perception of pain and response to it. In accord with this conception, it is theorized that a multidimensional approach to chronic pain syndromes and abnormal pain behaviors is most effective at reducing symptoms and associated loss of function. Medical and surgical treatments may address the biologic underpinnings of pain experience, although their utility in the treatment of abnormal pain behaviors is controversial. As yet, there is no firm evidence that antidepressants or any other pharmaceutical agent can be regarded as the best approach for treating somatoform disorders. There is also no information on the optimum dose, duration of treatment, or long-term outcome in patients treated with such medication for this indication.

Psychologic and social factors that play a pivotal role in the development of abnormal pain behaviors need to be addressed through various interventions. Comorbid conditions, such as depression, anxiety, and sleeping disorders, not only reinforce the undesirable effects of pain, but these psychologic factors may interfere with successful rehabilitation. There is growing evidence that cognitive-behavioral therapy (CBT) improves long-term rehabilitation success for patients with chronic pain symptoms. The primary aim of such interventions is to improve daily functioning, self-efficacy, and quality of life. In case of abnormal pain behaviors, CBT also helps to diminish fear-avoidance beliefs, catastrophizing, and other behavioral responses to pain, thus modifying the pain experience. Family therapy or psychodynamic psychotherapy may prove effective as well, because they address the social aspect of pain behaviors. However, there are no systematic reviews assessing efficacy of these methods.

Conversion symptoms, especially when acute, may undergo spontaneous resolution after explanation and suggestion. Some patients may benefit from education about the patterns of sensorimotor disturbance associated with alteration in neurotransmission, as in the case of major depression, thereby providing a cognitive framework for treatment. Hypnosis is also a potential intervention in the management of this disorder; its goals are to enhance symptom reduction and exploration. This can sometimes also be used to evoke memories of a traumatic event having a positive link with the symptoms. Although there are many anecdotal accounts of the efficacy of hypnosis in conversion disorder, a recent randomized controlled trial found that hypnosis had no additional effect on treatment outcome.

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