# Conversion & somatic symptom disorders

The curriculum's third named type, and in Nepal, arguably the most important differential a psychosocial counselor ever makes: conversion versus epilepsy.

## Conversion Disorder (Functional Neurological Symptom Disorder)

Real neurological symptoms, paralysis, seizures, blindness, mutism, that are incompatible with any neurological disease. The client is not pretending.

**In plain words:** Real symptoms that look neurological (fits, weakness, blindness, losing the voice) without a disease to explain them; the body is speaking.

DSM-5 Criteria

1. One or more symptoms of altered voluntary motor or sensory function.
2. Clinical findings show **incompatibility** between the symptom and recognised neurological or medical conditions (e.g., a normal EEG recorded during a "seizure", though this alone does not exclude every form of epilepsy; tremor that stops when attention shifts).
3. Not better explained by another medical or mental disorder.
4. Clinically significant distress, impairment, or warrants medical evaluation.
Symptom types:

- Weakness or paralysis
- Abnormal movement
- Swallowing
- Speech
- Attacks or seizures (PNES)
- Anaesthesia or sensory loss
- Special sensory (vision, hearing)
- Mixed
DSM-5 dropped the old requirement to prove a psychological stressor, and "la belle indifférence" is not diagnostic.

|  | Epileptic seizure | Conversion (psychogenic non-epileptic) attack |
| --- | --- | --- |
| Onset | Sudden, any time: including sleep, alone | Gradual, usually with witnesses present |
| Movements | Rhythmic, synchronous jerking; stereotyped | Asynchronous thrashing, pelvic thrusting, side-to-side head shaking, arc de cercle |
| Eyes | Usually open or deviated | Usually closed, resist opening |
| Injury & incontinence | Side-of-tongue biting is fairly specific; falls and incontinence occur | Also occur; no single sign settles it, video-EEG does |
| Duration | Typically 1–2 minutes | Often prolonged, waxing-waning, >5 minutes |
| After the attack | Confusion, drowsiness (post-ictal) | Rapid recovery, may cry; recall variable |
| EEG | Epileptiform activity | Normal during attack |

Nepal: including mass conversion

This is a signature Nepali presentation: episodes of fainting, jerking, or possession-like states ("chhopne") in adolescent girls, often spreading through a school classroom or hostel within hours: **mass conversion / mass psychogenic illness**, repeatedly reported in Nepali districts. The National Mental Health Survey 2020 found dissociative disorder in 1.0% of adults currently and somatic symptom disorder in 0.5%. See [Nepal in numbers](https://manoatlas.com/data.md).

Respond by separating affected students calmly, avoiding dramatic audiences, ruling out real medical causes, and working with the community's spiritual explanation rather than against it. Never announce "it is all in her mind": the symptom is real, involuntary, and treatable, and the family's cooperation is your main instrument.

Refer first-ever seizures for neurological work-up always.

**Also in this chapter:** **Somatic Symptom Disorder** (300.82/F45.1): one or more distressing bodily symptoms *plus* excessive thoughts, anxiety, or time devoted to them, persistent (typically >6 months); the symptom may or may not be medically explained: what is disordered is the response to it. **Illness Anxiety Disorder** (300.7/F45.21): preoccupation with *having* a serious illness, with minimal or no somatic symptoms; checking or avoidance; ≥6 months.

**A worked example:** A 35-year-old named Deepa has episodes of sudden collapse at school assemblies. Teachers assume she is pretending, but a counselor notes that her episodes last over ten minutes with eyes closed and gradual recovery, consistent with a conversion attack rather than epilepsy. A video-EEG confirms the diagnosis and the counselor begins psychoeducation about how stress converts into symptoms.

Two attacks side by side. Read the whole timeline, not one sign: onset, duration, the eyes, and what the person is like afterwards. The differences are typical, never absolute, which is why the referral is the safe move.

A skill to try · two minutes

**A kind body check-in.** Sit comfortably and move attention slowly from feet to head, asking only "what do I notice?", never "what is wrong?". When the body is where distress speaks, listening to it with curiosity instead of fear is itself a message: you are heard.

A coping skill, not a treatment: it supports care, it does not replace it.

Key points

1. Conversion disorder is real neurological-looking symptoms (fits, paralysis, blindness) without a matching disease; it is not faking.
2. Telling conversion from epilepsy is the counselor's most important differential in Nepal; when unsure, refer for medical assessment.
3. 'Chhopne' in a school can spread from person to person (mass conversion); calm separation and reassurance stop it.
Learn more

Pick one, not all: these are chosen to be light, not exhaustive.

Website[neurosymptoms.org (Prof. Jon Stone)](https://neurosymptoms.org): The best plain-language FND/conversion guide: made for patients; use it for psychoeducation.

Book chapter**Where There Is No Psychiatrist: "Medically unexplained symptoms"**: Step-by-step handling of exactly these presentations.


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*Source: https://manoatlas.com/somatic · Licence: CC BY-NC-SA 4.0. Mano Atlas is an educational resource, not a diagnostic tool.*