Second edition

07.qxd 3/10/08 9:35 AM Page 299
Conversion disorder is characterized solely by conversion
symptoms. By contrast, in these two other disorders one sees
multiple other symptoms. In Briquet’s syndrome there are
multiple complaints referable to organ systems other than the
central nervous system, and hence one typically hears of complaints
regarding pulmonary, gastrointestinal, and musculoskeletal
functioning. In schizophrenia, one sees a variable
mixture of psychotic symptoms, such as delusions, hallucinations,
loosened associations, and overall bizarreness.
Malingering is distinguished from conversion disorder
in that, in the case of malingering, the patient does intentionally,
and with full awareness, feign the symptom that,
in turn, clearly answers to an obvious motivation. For
example, a patient who had been in a minor motor vehicle
accident might feign a paralysis, and maintain that weakness
until a large legal settlement had been obtained.
Factitious disorder must also be considered, and here the
motivation is simply to be a patient in the hospital.
TREATMENT
After the diagnosis is made, one should inform the patient in
a calm and quietly authoritative way that the investigation
and testing indicate that the nervous system is intact and not
damaged. One may then go on to add that although it is not
known why these symptoms have appeared, it is known that,
with time, most patients recover. In some cases, especially
those with conversion symptoms involving motor function,
such as paralysis, engaging the patient in a course of physical
therapy may be followed by a rapid resolution of symptoms
(Watanabe et al. 1998). Hypnosis and psychotherapy have
both been utilized, and, anecdotally, with success.
Somatization disorder
Somatization disorder, also known as Briquet’s syndrome
(in honor of Pierre Briquet, who first described it in 1859),
is characterized by multiple complaints, referable to multiple
organ systems, all occurring in the absence of any
disease entity that could reasonably account for them
(Perley and Guze 1962). These complaints persist chronically,
and typically occasion multiple evaluations, hospitalizations,
and often-needless diagnostic procedures or
surgeries. Conservative estimates indicate a lifetime prevalence
in females of from 0.2 to 2 percent; although Briquet’s
syndrome may also occur in males, this is probably very
uncommon, if not rare (Smith et al. 1985).
CLINICAL FEATURES
This syndrome generally first appears in teenage years;
onset past the age of 30 is extremely rare.
Patients tend to be excessively vague or dramatic in
relating their history, often moving restlessly from one
symptom to another, never lingering long enough on one
symptom to give an adequately detailed account. As noted
7.7 Somatoform disorders 299
earlier, multiple complaints are heard, implicating multiple
organ systems, including the gastrointestinal tract, the genitourinary
system, central and peripheral nervous systems,
and the musculoskeletal system. There is debate as to how
many symptoms and how many organ systems are required
to make a diagnosis: a conservative approach requires at
least one unexplained complaint from each system.
Gastrointestinal complaints often center on vague and
poorly localized abdominal pain, often accompanied by nausea
and bloating. Constipation is common, diarrhea somewhat
less so, and patients often complain of multiple food
intolerances. Rectal pain or burning may also be present.
Of genitourinary complaints, irregular, painful or heavy
menstrual flow is prominent, and patients who have been
pregnant may complain of having had severe, intractable
vomiting throughout the entire pregnancy. Decreased
libido is common; females may complain of decreased vaginal
lubrication and dyspareunia, and males may complain
of erectile dysfunction. Dysuria and partial urinary retention
may also occur.
Musculoskeletal complaints include backache, arthralgia,
and diffuse chest pain.
Central and peripheral nervous system complaints
include paralysis, anesthesia, ataxia, deafness, blurry vision,
diplopia, blindness, dizziness, fainting, pseudoseizures,
globus hystericus, aphonia, and headache.
The large number of complaints, and the inability of the
physician to pin the patient down as to details, often make
the interview very frustrating for the physician, and it is
typical to find chart entries indicating merely that the
review of systems was ‘diffusely positive’. Many physicians
turn to the physical examination with some relief, hoping
to determine some definite findings. Generally, however, if
there are any findings, they are typically minor and not
indicative of any disease or condition that could possibly
account for the patient’s multitudinous complaints.
When physicians attempt to reassure patients regarding
the benign nature of the examination, they are often met
with disbelief, if not hostility, and patients typically
demand tests, and when basic tests are unremarkable, the
demands persist. Some physicians may call it quits at this
point, but others will proceed to invasive procedures or
even to surgery. In some cases, patients have welcomed so
many abdominal surgeries that they finally develop a ‘battlefield
abdomen’. ‘Doctor shopping’ is common, as exasperated
physicians ‘fire’ their patients, or patients, dissatisfied
with the diagnostic approach offered by their physicians,
move on to find a more aggressive diagnostician.
In addition to these multiple complaints, depression
and panic attacks are common, as is alcohol abuse or alcoholism.
Personality disturbances of the borderline, histrionic,
or antisocial type, are also common.
COURSE
Briquet’s syndrome typically pursues a chronic course,
with the intensity and variety of complaints fluctuating