Because somatoform disorders are placed at the crossroads between physical and mental disorder, their differential diagnosis tends to be quite inclusive and elaborate. However, several features of these disorders can help the differential diagnosis. Table 17.1 lists features that can help in deciding whether idiopathic physical symptoms may have a psychiatric cause.

There is an association between conversion disorder and antisocial personality disorder. The onset of the disorder is usually acute, and symptoms or deficits are usually of short duration. The symptoms usually do not conform to known anatomical pathways and physiological mechanisms but instead follow the individual’s conceptualization of his or her illness. Confronting the patient about the so-called “false nature” of his or her symptoms is contraindicated. In acute cases, reassurance and suggestion of recovery coupled with early rehabilitation are the treatments of choice. Schizoid disorder is not comorbid in patients with conversion disorder.

The ratio of women to men among adult conversion disorder patients is at least 2:1 and as much as 10:1; among children, an even higher predominance is seen in girls (not boys). Symptoms are more common on the left side than the right side of the body in women (not vice versa). Women who present with conversion symptoms are more likely to subsequently develop somatization than women who have not have conversion symptoms. An association exists between conversion disorder and antisocial personality disorder in men (not borderline personality disorder). Men with conversion have more often been involved in occupational or military accidents (not women).

Many conversion disorders simulate acute neurological pathology (e.g., strokes and disturbances of speech, hearing, or vision). However, conversion disorders are not associated with the usual pathological neurodiagnostic signs or the underlying somatic pathology. Conversion symptoms (e.g., anesthesias and paresthesias produced by a conversion disorder) do not conform to usual dermatomal distribution of the underlying peripheral nerves; rather, the signs and symptoms of a conversion disorder typically conform to the patient’s concept of the medical condition.

Conversion disorders seem to change or convert the psychic energy of the turmoil of acute conflict into a personally meaningful metaphor of bodily dysfunction. Turbulence of the mind is transformed into a somatic statement, condensing and focusing concepts, role models, and communicative meanings into one or several physical signs or symptoms of dysfunction. These somatic representations often simulate an acute medical calamity; initiate urgent, sometimes expensive medical investigation; and produce disability. In primitive settings, however, certain conversion symptoms have been taken as tokens of religious faith and even as expressions of witchcraft.

Cogwheel rigidity is an organic sign secondary to disorders of the basal ganglia and not a sign of conversion disorder. In conversion disorder, anesthesia and paresthesia, especially of the extremities, are common. All sensory modalities are involved, and the distribution of the disturbance is inconsistent with that of either central or peripheral neurological disease. Thus, one sees the characteristic stocking-and-glove anesthesia of the hands or feet or hemianesthesia of the body beginning precisely at the midline. Motor symptoms include abnormal movements and gait disturbance, which is often a wildly ataxic, staggering gait accompanied by gross, irregular, jerky truncal movements and thrashing and waving arms (also known as astasia-abasia). Normal reflexes are seen. The patient shows no fasciculations or muscle atrophy, and electromyography findings are normal.

Neurological disorders (e.g., dementia and other degenerative diseases), brain tumors, and basal ganglia disease must be considered in the differential diagnosis for conversion disorder. For example, weakness may be confused with myasthenia gravis, polymyositis, acquired myopathies, or multiple sclerosis. Optic neuritis may be misdiagnosed as conversion disorder blindness. Other diseases that can cause confusing symptoms are Guillain-Barré syndrome, Creutzfeldt-Jakob disease, periodic paralysis, and early neurological manifestations of acquired immunodeficiency syndrome (AIDS). Conversion disorder symptoms occur in schizophrenia, depressive disorders and anxiety disorders, but these other disorders are associated with their own distinct symptoms that eventually make differential diagnosis possible.

Conversion disorder is an illness of symptoms or deficits that affect voluntary motor or sensory functions, which suggest another medical condition, but that is judged to be caused by psychological factors because the illness is preceded by conflicts or other stressors. Somatization disorder is an illness of multiple somatic complaints in multiple organ systems that occurs over a period of several years and results in significant impairment, treatment seeking, or both. Sensorimotor symptoms also occur in somatization disorder. But somatization disorder is a chronic illness that begins early in life and includes symptoms in many other organ systems (not conversion disorder). In hypochondriasis (general and nondelusional preoccupation with fears of having, or the idea that one has a serious disease), as opposed to conversion disorder, patients have no actual loss or distortion of function; the somatic complaints are chronic and are not limited to neurological symptoms, and the characteristic hypochondriacal attitudes and beliefs are present. If the patient’s symptoms are limited to pain, pain disorder (not conversion disorder) can be diagnosed. Conversion disorder is acute and generally transient and usually involves a symptom rather than a particular disease (not vice versa). This is in contrast to hypochondriasis, which involves a particular disease.

During the course of somatization disorder, the patient has complained of pain and gastrointestinal, sexual, and pseudoneurological symptoms that are not explained by a known medical condition

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