Psychotic Symptoms in Dissociative (Conversion) Disorder in Two Tertiary Care Hospitals in Bangladesh

Dissociative (conversion) disorder (DCR) has a long and controversial history. Some authors wish to classify it with somatoform disorders separate from dissociative disorders; many researchers keep it with DCR. Symptoms pattern also varies in different cultures. This study used the criteria of International Classification of Diseases Tenth Edition (ICD-10). Study was aimed to see the presenting symptom profile of dissociative (conversion) disorder more focusing on psychotic symptoms in tertiary care hospital in Bangladesh. This cross sectional observation was carried out in two different tertiary care hospitals in Dhaka city with preformed pretested questionnaire. Data were collected from 100 consecutive patients from July 2005 to June 2006 and data were analyzed by Statistical Package of Social Science (SPSS) 16.0. Pattern of dissociative (conversion) disorder indicated that symptoms presentations are different in Bangladesh which is difficult to categorize using existing criteria of ICD-10. Among 100 consecutive patients diagnosed as dissociative (conversion) disorder 13 patients had psychotic symptoms. Psychotic presentation of conversion disorder often creates doubts among the clinicians. Careful history taking, identifying the underlying psychosocial stressors will help clinicians to diagnose them accurately. It should be noted that the pattern of presentation in South Asia may be different due to role of culture on symptoms presentation in this region.

Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment

PURPOSE OF REVIEW

This paper examines the overlap of conversion disorder with chronic pain conditions, describes ways to assess for conversion disorder, and provides an overview of evidence-based treatments for conversion disorder and chronic pain, with a focus on conversion symptoms.

RECENT FINDINGS

Conversion disorder is a significant problem that warrants further study, given that there are not many well-established guidelines. Accurate and timely assessment should help move treatment in a more fruitful direction and avoid unnecessary medical interventions. Advances in neuroimaging may also help further our understanding of conversion disorder. Creating a supportive environment and a collaborative treatment relationship and improving understanding of conversion symptoms appear to help individuals diagnosed with conversion disorder engage in appropriate treatments. Novel uses of earlier treatments, such as hypnosis and psychodynamic approaches, could potentially be beneficial and require a more vigorous and systematic study. There are treatments that produce significant improvements in functioning and reduction of physical symptoms from conversion disorder even for very severe cases. Hypnotherapy, cognitive behavioral therapy, and inpatient multidisciplinary treatment with intensive physiotherapy for severe cases have the most evidence to support reduction of symptoms. Components of treatment for conversion disorder overlap with treatments for chronic pain and can be used together to produce therapeutic effects for both conditions. Treatment needs to be tailored for each individual's specific symptoms.

[Functional neurological movement disorders]

Functional movement disorders include motor dysfunctions which are not explained by relevant neurological examination. The prevalence of the disorders is relatively high (10-15%) within an ordinary neurological patient group. Untreated, prognosis for the conditions is poor, and neurological imaging has not yet provided explanatory hypotheses. Treatment studies are sparse, but a heterogenous group of studies of intense, multidisciplinary treatment programmes all point toward good and promising treatment effects. This is not reflected in the actual treatment capacity in Denmark.

[CONVERSION REACTION AS A MOTOR DISABILITY: DIAGNOSIS, TREATMENT AND REHABILITATION THERAPY]

The Rehabilitation Medicine specialists are frequently confronted with paralyzed patients due to a conversion-somatoform etiology. This article describes our model of diagnosing, treating and rehabilitating these patients.

Functional Neurological Symptom Disorder in Youth

Functional neurological symptom disorder (FNSD) is characterized by motor or sensory impairments inconsistent with recognized neurologic conditions. Usually emerging in adolescence, somatic symptoms remain challenging for the physician to assess and treat. Also termed "conversion disorder," FNSD has been recently reconceptualized with greater diagnostic emphasis on positive neurologic findings while eliminating the requirement for a precipitating stressor. This has broadened the initial treatment emphasis from mandating psychotherapeutic engagement to a more collaborative model that requires open communication of neurologic findings and strives to align with families' perspectives. Severe disorders necessitate a unified treatment approach from several clinical specialties, including behavioral approaches, and pediatricians may play a central role in the management of youth with FNSD as well as their families. Treatment engagement can be facilitated by validating the distress of the patient, providing resources to address diagnostic questions and parental concerns, and implementing shared goals toward rapid return to self-efficacy. [Pediatr Ann. 2016;45(10):e356-e361.].

Mass Psychogenic Illness Presenting as Acute Stridor in an Adolescent Female Cohort

Objectives:

We describe a cohort of patients with an unusual presentation of stridor, their evaluation and management, and their outcome. We review the pertinent English-language literature.

Methods:

We performed a retrospective review of the records of 12 adolescent patients treated for acute-onset inspiratory stridor at the Departments of Otolaryngology-Head and Neck Surgery and Allergy and Immunology at the University of South Florida and the Department of Speech Pathology at the H. Lee Moffitt Cancer Center and Research Institute. Two additional patients received treatment elsewhere. Demographic, historical, and laboratory data, physical examination findings, and follow-up information were extracted. A review of both the Hillsborough County Department of Health epidemiological report and the English-language literature was performed.

Results:

Fourteen female patients who attended a local high school developed audible inspiratory noise. Twelve of the 14 were seen at the University of South Florida Ear, Nose and Throat Center. The remaining 2 patients were evaluated by outside otolaryngologists but were included in all reports from the Department of Health. Environmental studies did not find noxious chemical or biological agents in the students' environments to explain the development of the symptoms. Physical and videostroboscopic examination identified two distinct laryngeal findings causing the audible stridor. One involved paradoxical vocal fold movement, and the other, supraglottic mucosal collapse into the airway. All patients underwent rigorous speech pathology intervention and structured treatment with either complete resolution or significant improvement, seen both clinically and on videostroboscopic evaluation.

Conclusions:

Audible stridor can arise from numerous disease processes. In the vast majority of presentations it occurs sporadically and on an individual basis. Our cohort is especially unusual because of the sheer number of patients. Our presentation of a case of mass psychogenic illness as the cause of vocal cord dysfunction with additional findings of laryngomalacia within a group of adolescent girls is the first in the English-language literature. The key to the diagnosis is recognition of the disorder and susceptible individuals by using a thorough physical examination with emphasis on the laryngoscopic and videostroboscopic findings. The systematic approach, undertaken by a team including an otolaryngologist, an allergist, a speech pathologist, and an epidemiologist, proved to be effective in the management of this complex disorder and highly unusual situation.

Hypnosis as therapy for functional neurologic disorders

Suggestion in hypnosis has been applied to the treatment of functional neurologic symptoms since the earliest descriptions of hypnosis in the 19th century. Suggestion in this sense refers to an intentional communication of beliefs or ideas, whether verbally or nonverbally, to produce subjectively convincing changes in experience and behavior. The recognition of suggestion as a psychologic process with therapeutic applications was closely linked to the derivation of hypnosis from earlier healing practices. Animal magnetism, the immediate precursor of hypnosis, arrived at a psychologic concept of suggestion along with other ideas and practices which were then incorporated into hypnosis. Before then, other forms of magnetism and ritual healing practices such as exorcism involved unintentionally suggestive verbal and nonverbal stimuli. We consider the derivation of hypnosis from these practices not only to illustrate the range of suggestive processes, but also the consistency with which suggestion has been applied to the production and removal of dissociative and functional neurologic symptoms over many centuries. Nineteenth-century practitioners treated functional symptoms with induction of hypnosis per se; imperative suggestions, or commands for specific effects; "medical clairvoyance" in hypnotic trance, in which patients diagnosed their own condition and predicted the time and manner of their recovery; and suggestion without prior hypnosis, known as "fascination" or "psychotherapeutics." Modern treatments largely involve different types of imperative suggestion with or without hypnosis. However, the therapeutic application of suggestion in hypnosis to functional and other symptoms waned in the first half of the 20th century under the separate pressures of behaviorism and psychoanalysis. In recent decades suggestion in hypnosis has been more widely applied to treating functional neurologic symptoms. Suggestion is typically applied within the context of other treatment approaches, such as cognitive-behavioral, rehabilitative, or psychodynamic therapy. Suggestions are generally symptom-focused (designed to resolve a symptom) or exploratory (using methods such as revivification or age regression to explore experiences associated with symptom onset). The evidence base is dominated by case studies and series, with a paucity of randomized controlled trials. Future evaluation studies should allow for the fact that suggestion with or without hypnosis is a component of broader treatment interventions adapted to a wide range of symptoms and presentations. An important role of the concept of suggestion in the management of functional neurologic symptoms is to raise awareness of how interactions with clinicians and wider clinical contexts can alter expectancies and beliefs of patients in ways that influence the onset, course, and remission of symptoms.

Inpatient treatment for functional neurologic disorders

Patients with functional neurologic disorders present to clinicians with a variety of symptomatic manifestations, with various levels of severity, chronicity, and comorbidity, as well as with various degrees of past adversity, intrinsic resilience, and available external support. Clearly, treatment must be individualized. For those patients who have been severely or chronically impaired, especially if adequate prior outpatient treatments have failed, inpatient treatment that integrates the various modalities outlined here provides a rational route of rescue from a course otherwise potentially characterized by protracted dependence and disability. Based on the data currently available, we believe this treatment approach is worthy of further study to refine the component treatment strategies and enhance the potentially most effective ingredients. For patients with severe levels of disability, who could be managed in a multimodal day-treatment program, that approach also warrants further consideration.

Transcranial magnetic stimulation and sedation as treatment for functional neurologic disorders

Functional neurologic disorder (FND), also known as conversion disorder, is common and often associated with a poor prognosis. It has been relatively neglected by research and as such there is a conspicuous lack of evidence-based treatments. Physical and psychologic therapies are the main treatment modalities, over and above reassurance and sensitive explanation of the diagnosis. However there are two other historic treatments that have seen a recent resurgence of interest and use. The first is electric stimulation, which was initially pioneered with direct stimulation of nerves but now used indirectly (and therefore noninvasively) in the form of transcranial magnetic stimulation (TMS). The second is (therapeutic) sedation, previously known as "abreaction," where it was mostly used in the context of psychologic investigation and treatment, but now increasingly advocated during rehabilitation as a way to therapeutically demonstrate reversibility of symptoms. This chapter introduces the background of these treatment modalities, their evolution into their current applications before critically evaluating their current evidence base and exploring possible mechanisms of action. It also tentatively suggests when they should be considered in current practice and briefly considers their future potential. In summary there is encouraging preliminary evidence to suggest that both TMS and sedation may be effective treatments for FNDs.

[Conversion Disorder in Children and Adolescents]

BACKGROUND

Conversion disorder is diagnosed late, by exclusion and with a high risk of complications. There is a wide experience in adults that is not extrapolated to paediatric patients. According to the literature, the prognosis is better in children, but this changes when other variables such are included, such as comorbidities, late diagnosis and a very convincing social image of the neurological disease.

OBJECTIVE

To review the medical literature on the clinical features, diagnosis, comorbidities and treatment of this disorder.

METHODS

A literature research was performed on Medline and Pubmed, the terms used were "conversion disorder", pseudoseizures, treatment, clinic, children ("conversion disorder" OR hysteria OR hysterical) (child OR children OR childhood OR pediatric OR paediatric). The most relevant material found is included in this review.

CONCLUSIONS

Conversion disorder is often an imprecise diagnosis in high complexity paediatric services. No consensus was found in the literature search on how to treat patients after the initial diagnosis. The evidence that it becomes chronic is not strong enough, just as the evidence is not convincing enough to argue that comorbidity factors are those maintained over time. Clearly, there is no medical experience of the natural history of this disorder in children and adolescents. It is only known is that it is a complex condition, on which there is experience only in the diagnosis and treatment of the acute state, but not so in the long-term care. It is proposed that each patient is studied in detail in order to define the psychiatric diagnosis and its treatment.

Psychogenic speech disorder--a case report

BACKGROUND

Conversion (dissociative) disorder is a psychiatric disorder in which somatic symptoms or deficits are present in the absence of a definable organic cause. The etiology of this disorder is not yet fully understood. The most characteristic presentations are: pseudosensory syndromes, pseudoseizures, psychogenic movement disorders and pseudoparalysis. Psychogenic speech disorder is a rare form of conversion (dissociative) disorder. The aim of present case study is to complete the knowledge on this subject.

SUBJECT AND METHODS

The article presents a case of a fifty year old woman who developed psychogenic disorder of speech after being degraded to a lower position at work. After excluding organic background of observed symptoms, the diagnosis of conversion (dissociative) disorder was stated and adequate therapy was implemented, within the capabilities of the Ward.

RESULTS

Partial remission of presented symptoms was achieved as a result of psychopharmacotherapy and psychotherapy.

CONCLUSIONS

Before stating the diagnosis of conversion (dissociative) disorder, possible somatic causes of the observed symptoms should be excluded. Special attention should be drawn to the importance of studying the psychological and family context of this case and the patient's difficulty to understand and accept that produced symptoms might be triggered by a psychogenic factor.

23 y/o female with dysphagia--Evaluation, intervention and resolution of symptoms in the Psychiatry consultation setting

Dysphagia is a symptom shared by many medical and psychiatric conditions. A thorough Psychiatric evaluation could rule in a functional or psychological etiology. If a Psychological etiology is identified, a psychodynamic formulation could help the consultation psychiatrist clarify the origin of the symptom and provide a better explanation to the patient and medical team, resulting in improved care by prevention of unnecessary medical interventions, improvement of symptoms and individualization of the treatment.

A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders

Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

Psychogenic limp in a child: are we aware of it?

A 10-year-old child presented with a limp for 9 months. The child was keeping his right knee extended and foot in the equinus position. The child had been investigated by numerous laboratory investigations and imaging procedures during the initial 9 months, but no organic cause was found. Without any conclusive diagnosis, the child was being managed by physical therapy. During examination in our clinic, the variable contraction of the quadriceps muscle raised the possibility of a psychiatric disorder. A psychiatrist's opinion was sought and the child was found to have dissociative motor disorder. His conflict was identified and treated by cognitive behavioral therapy. The child walked normally after 1 week. A psychogenic limp is often not suspected by the orthopedic surgeon in the evaluation of a limp. The involvement of a psychiatrist in this evaluation may be helpful to identify the condition easily and even at the first instance.

'Hysteria' today and tomorrow

'Hysteria' (conversion disorder) remains in modern humanity and across cultures, as it has for millennia. Advances today in tools and criteria have afforded more accurate diagnosis, and advances in treatments have empowered patients and providers, resulting in a renewed interest in somatoform disorders. Future progress in understanding mechanisms may be influenced by developments in functional neuroimaging and neurophysiology. No animal model exists for somatoform symptoms or conversion disorder. Despite the absence of a known molecular mechanism, psychotherapy is helping patients with conversion disorder to take control of their symptoms and have improved quality of life, shedding light on what was once an enigma.

[Management of patients with conversion disorder]

The symptoms of conversion disorder are not due to conscious simulation. There should be no doubt that the symptoms of conversion disorder are genuine, even if scans do not reveal any abnormalities. The management of patients with conversion disorder starts with an explanation of the diagnosis. The essence of this explanation is that patients first hear about what the diagnosis actually means and only after this about what they do not have. When explaining the diagnosis it is a good idea to use metaphors. The treatment of patients with conversion disorder is carried out together with a physical therapist. The collaboration of healthcare professionals who are involved in the treatment of a patient with conversion disorder should preferably be coordinated by the patient's general practitioner.

Globus hystericus

Globus hystericus (GH) is a subjective feeling of a lump or foreign body in the throat thought to involve psychogenic factors, a form of somatisation disorder. The more modern terms, globus sensation or globus pharyngeus, reflect recognition of one or more possible contributing anatomico-physiological factors, such as gastro-oesophageal reflux disease (GORD) or pharyngeal inflammation.

Miraculous healings of paralysis: a preliminary study on sources

The aim of the present paper has been to explore the medieval evidence on miraculous healings of paralysis and to confront it with modern medical knowledge. Paralysis has been selected as a model for such a study and St. Bernardino of Siena (1380-1444) as a model of a saintly healer. Analyzed were the primary sources and modern literature. Paralysis was found to be among the most frequent diseases in medieval miracle reports, including the healings by St. Bernardino. According to the hypothesis offered in the paper, the majority of medieval cases of "miraculously healed paralysis" was of conversive origin.

Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are clinical events resembling epileptic seizures but lacking abnormal cortical electrical discharges. They are involuntary manifestations of a psychological distress. PNES are less frequent in the pediatric population than in adults, they represent from 3.5 to 9% of patients admitted for prolonged video-EEG (PV-EEG). Diagnosis is rarely made on history only and PV-EEG is mandatory to obtain a definitive diagnosis. Children as young as 5 years can present with PNES. They are more frequent in girls except in school age children where boys are identically or more represented than girls. PNES can either present with subtle signs, even unresponsiveness, or prominent motor activity. Major differential diagnosis is absences, day dreaming, and complex partial seizures including hyperkinetic frontal seizures. PNES are usually rapidly registered during PV-EEG and provocative methods have not been thoroughly studied in children. Major risk factors are psychological stressors, such as school or family problems. Psychiatric conditions are less frequent than in adults though they should be looked for. Prognosis is better than in adults, and most children become PNES-free. There are no guidelines for treatment, however stressors should be addressed. In general, it should be clearly explained that PNES are not epileptic seizures.

[Hysterical conversion]

"Hysterical" conversion hasn't vanished, and remains a diagnostic, therapeutic and relational challenge for the clinician. Conversion may be associated with organic disease. From the clinical point of view, two subtypes of conversion symptoms, namely psychogenic nonepileptic seizures and functional movement disorders, have been individualized. Physical signs of neurological inconsistency, and classical arguments in favor of a psychological etiology have been recently reevaluated, which allows, along with the progress of neurological investigations, to minimize the rate of misdiagnosis. Functional neuroimaging has shed light on the brain mechanisms involved in conversion phenomena. From a nosological point of view, there is a tension between the whish to "banalize" the conversion symptoms as mere "functional neurological symptoms", which makes easier to communicate the diagnosis to the patient and may remove the stigma from the diagnosis; and the wish of certain authors to "revive" hysteria, emphasizing the core phenomenon of dissociation and its close relationship with trauma. Proposed treatment of conversion disorder are numerous, although poorly evaluated and often insatisfactory, but recent publications insist on the importance of communicating the diagnosis to the patient in a honest, nonjudmental and understandable way, at the earliest phase of the disorder.

Treatment of a severe conversion disorder in a 10-year-old boy: a case study and overview

Conversion disorder (CD) in children remains a major challenge both in pediatric and mental health clinics and is still a prevalent psychiatric disorder in developing countries. The authors describe a 10-year-old boy with the complaints of inability to walk, speak or eat, excessive drooling, urinary and fecal incontinence, disturbance from light and sound, and expression of needs only by eye movements. The patient diagnosed with CD was followed by the Department of Child and Adolescent Psychiatry with play therapy, individual psychotherapy and family therapy. At the end of three months, the patient was discharged. This is one of the most challenging cases of CD in children. The most important aim of the treatment is to understand the need for conversion symptoms and to constitute a healthy psychological environment for the child rather than to remove the physical symptoms.