Camptocormia induced by atypical antipsychotics and resolved by electroconvulsive therapy

We present a depressive patient who developed mild parkinsonian signs and camptocormia after the introduction of olanzapine. She had been treated before with other antipsychotic drugs. When camptocormia was diagnosed, olanzapine was withdrawn and levodopa was introduced. Depressive symptoms got worse and electroconvulsive therapy was tried. When the treatment was completed, her depression substantially improved and her posture became completely upright.

Hysterical paralysis

Hysterical paralysis is an uncommon type of conversion disorder. It can be difficult to diagnose. In cases in which symptoms are difficult to explain neuroanatomically or are functionally inconsistent, hysteria should enter into the differential diagnosis. We report a case of hysterical paralysis that had rapid improvement using physical therapy and antidepressant therapy.

Transcranial Magnetic Stimulation in Motor Conversion Disorder: A Short Case Series

The neurophysiologic mechanisms involved in nonorganic paralysis are unclear. Because there is no established standard therapy, the authors investigated the effect of repetitive transcranial magnetic stimulation (rTMS) in four patients with nonorganic limb paralysis. Within the framework of a treatment trial, the patients were treated over a period of 5-12 weeks with rTMS applied to the contralateral motor cortex. Stimulation frequency was 15 Hz, train length 2 seconds, intertrain interval 4 seconds; daily total number of stimuli 4000. In one patient, motor function was completely restored; two patients experienced a marked improvement correlating with rTMS treatment. By contrast, one patient who had been diagnosed as a malingerer did not improve. Apart from possible favorable psychological factors that could partly explain the rTMS-associated effects, high-frequency rTMS might have enhanced or substituted an insufficient input to the motor cortex from failing frontal executive areas, and thereby opened the way to a learning process that lead to the reacquisition of limb use. rTMS may have a therapeutic effect in motor conversion disorder and may help elucidate neurophysiologic aspects of this condition. The potential benefit of rTMS in motor conversion disorder should be evaluated in larger, controlled samples.

Über das Verhältnis von Traumatisierungen, Amnesie und Symptombelastung - eine empirische Pilotstudie/ On the relationship between traumatization, amnesia and symptom stress – an empirical pilot study

OBJECTIVES

In the present study we examined facial affective behavior in acutely traumatized patients undergoing EMDR therapy. Furthermore, we analyzed whether a decrease in emotional numbing was due to a reduction of symptoms. Amnestic tendencies were used as a moderator variable.

METHODS

The facial affective behaviour was coded using the Emotional Facial Acting Coding System, an instrument for the registration of facial movements with emotional relevance. The facial affective behavior of the patient's first and last EMDR session was compared.

RESULTS

A significant increase in facial affective behavior as well as an increase in mental complaints were found. Furthermore, the reduction in amnestic tendencies did not result in a reduction of symptoms.

CONCLUSIONS

Under the influence of the treatment it is possible to improve access to episodic affective memory. Nevertheless, a positive influence cannot be denoted at the end of the treatment.

Somatoform disorders in neurological practice

PURPOSE OF REVIEW

Patients with medically unexplained symptoms continue to intrigue, fascinate and frustrate clinicians. They are common in general medicine and often present with apparent neurological disorder. This review aims to provide insight into the recent literature that has sought to clarify epidemiology, diagnostic issues, aetiologic understanding and treatment of patients with psychogenic disorders who usually first present to neurologists.

RECENT FINDINGS

Somatoform disorders are common in neurological practice. A number of papers have addressed issues of epidemiology and identified that medically unexplained symptoms in neurological populations are higher than originally thought. A number of recent review papers have served to summarize areas of considerable information (e.g. treatments) and areas of rapid growth in knowledge (e.g. neuroimaging). Studies investigating the role of psychological factors are well represented and clarify our psychopathological understanding of somatoform disorders in patients presenting to neurologists. Treatment studies are few and continue to be limited by population sizes and study designs.

SUMMARY

Somatoform disorders are common in neurological populations. Comorbidity related to somatoform disorders with known organic neurological conditions requires further study. On account of the limitations of treatment studies, evidence-based clinical management of these patients is awaited.

A teenage girl with extreme tachypnea

Dyspnea and tachypnea are common presenting complaints in an emergency department. Respiratory and cardiac causes are the most common etiology. Functional respiratory disorders should be considered in patients with atypical presentation to avoid extensive investigations. We describe an adolescent who presented to our emergency department with extreme tachypnea.

[Early onset conversion disorder: a case report]

Conversion disorder is defined as the presence of functional impairment in motor, sensory and neurovegetative systems that cannot be fully explained by a general medical condition. In western countries, conversion disorder is rare in children and adolescents. However, clinical studies from our country demonstrated a high frequency of conversion disorder diagnosis in child and adolescent psychiatry clinics. Conversion disorder is more frequently seen in adolescents and young adults compared to children. The likelihood of this disorder in children younger than five years of age is very low. This case report presents an 8 years old patient with conversion disorder diagnosis whose complaints started at three years of age. Her clinical condition had been continuous and resistant to non-psychiatric treatment approaches. Her complaints included inability to stand up and walk, complete bed dependence, presence of jerking type of movements in both legs, contractures as a result of decreased muscle movements and joint use, and presence of curving in her back due to continuous sitting bent to one side. Therapeutic interventions had been successful and the patient completely recovered. In this paper, the clinical presentation of conversion disorder, possible etiological factors and how these factors were handled, concrete treatment strategies and the follow-up of this patient are discussed. In addition, importance of early diagnosis and treatment of conversion disorder in children in our country and requirement of interdisciplinary cooperation in treatment are emphasized.

[Epilepsy and pseudoseizures derived from their dissociation]

Many epileptic patients have pseudoseizures (psychogenic nonepileptic seizures mimicking epileptic seizures) derived from their dissociation (conversion) or other psychiatric symptoms. The pseudoseizure cast many problems on medical support for their management. In this article I reported the result of investigation of pseudoseizures in an epilepsy unit in department of psychiatry, National Center Hospital for Mental, Nervous, and Muscular Disorders, National Center of Neurology and Psychiatry. And I reffered to treatment and prognosis of pseudoseizures. The key points for psychiatrists in treating epileptic patients having pseudoseizures were; 1) not to hesitate to consult with specialists about diagnosis, 2) to distinguish a pseudoseizure from an epileptic seizure and to treat them separately, 3) not to treat seizure phenomena but patients by keeping reliable relationship with them.

Psychosocial interventions for conversion disorder

BACKGROUND

Conversion disorder is an alteration or loss of physical functioning suggestive of a physical disorder that is thought to be due to a psychological stressor or conflict. The fact that many theories about the cause of conversion disorder focus on psychological and social factors would suggest that a psychosocial intervention might be of most benefit.

OBJECTIVES

To investigate the efficacy of psychosocial interventions on people diagnosed with conversion disorder compared with standard care, a biological intervention or another psychosocial intervention.

SEARCH STRATEGY

We searched the Cochrane Depression, Anxiety and Neurosis Group Trials Register (May 2004), various databases on OVID (February 2004), handsearched reference lists and textbooks on conversion disorder and contacted relevant authors.

SELECTION CRITERIA

We included all randomised controlled trials that compared psychosocial interventions for conversion disorder with standard care or other interventions (biological or psychosocial).

DATA COLLECTION AND ANALYSIS

We reliably selected, quality assessed and extracted data from the studies. For dichotomous outcomes we calculated a relative risk with its associated 95% confidence interval and a number needed to treat. For continuous data we calculated a weighted mean difference.

MAIN RESULTS

The search identified 260 references, 217 were clearly not relevant to this review and excluded on the basis of their titles and abstracts, 40 more were excluded after reading the full papers (the reasons are given in the excluded studies tables) and only three studies (total n =119) met the inclusion criteria. One study was concerned with paradoxical injunction therapy and the other two studied the value of hypnosis. The three studies had different interventions and control groups so the results could not be combined. All of the studies were of poor methodological quality and it is therefore difficult to place much value on the results of the studies. We were unable to include some data because of poor reporting.

AUTHORS' CONCLUSIONS

Randomised studies are possible in this field. The use of psychosocial interventions for conversion disorder requires more research and it is not possible to draw any conclusions about their potential benefits or harms from the included studies.

Pseudoseizures in children: a profile of 50 cases

In contrast to adulthood hysterical disorders, childhood hysteria has not been accorded due recognition. Pseudoseizures are paroxysmal alterations in behavior that resemble epileptic seizures but are without any underlying organic cause. There is paucity of literature on pseudoseizures in children. In the present descriptive study of 2 years' duration, a series of consecutively seen 50 children with pseudoseizures is reported. After detailed history from parents, various socio-demographic and clinical variables were noted. Of 110 children seen with conversion disorder, 50 had pseudoseizures (45.5%). The average age was 8.2 years in boys and 9.4 years in girls. There were 28 girls (56.0%) and 22 boys (44.0%), and the majority of patients had the pseudoseizures for 1 to 3 months. When the mode of referral was studied, 52% were referred from pediatric outpatient department and the majority were referred to rule out comorbid psychiatric disorder. The fits mimicking generalized tonic-clonic seizures were most common and the duration of fits ranged from 10 to 35 minutes. The most common frequency of fits was 5 to 6 per week. The average duration of symptoms was 2.6 months in boys and 3.2 months in girls. Only 14 patients (28%) gave the history of having seen the fits in a relative or schoolmate. School phobia and the fear of examinations were the most common precipitating factors. Separation anxiety disorder, school phobia, and mood disorders were common comorbid diagnoses. The patients were put on appropriate drug treatment and/or psychotherapy for 3 months. Of 50 cases, 36 (72.0%) remitted, 10 (20.0%) showed a decrease in frequency of pseudoseizures, and 4 (8.0%) did not improve. With correct diagnosis and treatment, the children with pseudoseizures have a good outcome.

[Somatization -- conversion -- dissociation: strategies for behavior therapy]

Modern cognitive behavioral approaches for the treatment of patients with medically unexplained somatic symptoms have been developed on the basis of the classification systems DSM-IV and ICD-10. These systems define somatoform disorders as a homogeneous clinical group. Behavior therapy has additionally developed vicious circle models specifying etiological, triggering and maintaining factors. Treatment goals and strategies can be derived directly from these models. The main components are: (1) motivation of patients to accept the psychotherapeutic approach; (2) introduction of alternative explanations of the symptoms on the basis of both biomedical as well as psychosocial mechanisms; (3) evaluation of the new explanations by patient and therapist; (4) reduction of avoidance and inadequate illness behaviour. Health economical aspects are particularly important because patients with somatoform disorders tend to overuse medical services and are thus considered an expensive problem group for the health system.

Trauma-related dissociative (conversion) disorders in children and adolescents--an overview of assessment tools and treatment principles

A high proportion of patients in child and adolescent psychiatry with significant dissociative symptomatology after early childhood traumatization may go undiagnosed, be wrongly diagnosed and/or inappropriately treated. The diagnostics and treatment of dissociative disorders have been limited by lack of comprehensive, reliable and valid instruments and the ongoing polarization and fierce controversy regarding treatment. However, recent neurobiological findings of neurochemical, functional and structural cerebral consequences of early stressful childhood experiences point out a need for active, early and effective identification and treatment interventions. We present an update on assessment tools available in the Nordic countries, and an overview of different appropriate therapeutic intervention models for children and adolescents. A systematic overview of studies of dissociation in children and adolescent published over the last decade disclosed a total of 1019 references. The 465 papers describing aspects of assessment tools and/or treatment were studied in detail. Reliable and valid screening questionnaires and diagnostic interviews for children and adolescents now allow for effective early identification of dissociative disorders. A combination of individual psychotherapy, pharmacotherapy and family therapy are often required to handle dissociative disorders in children and adolescents. Cognitive-behavioural therapy, hypnotherapy, Eye-Movement Desensitization-Reprocessing (EMDR), psychodynamic therapy and an integrated approach are the main described psychotherapeutic approaches, but treatment of dissociation in children and adolescent does not require allegiance to any one particular treatment model. However, achievement of physical safety by providing a safe environment is a primary goal that supersedes any other therapeutic work. Assessments tools are now available, and appropriate therapeutic intervention models may hopefully contribute to reduce the risk of wrong diagnoses and inappropriate treatment of dissociative symptomatology in children and adolescents. However, controlled clinical trials of the various interventions and longitudinal outcome studies are needed.

Salient findings: A potentially groundbreaking study on the neuroscience of hypnotizability, a critical review of hypnosis' efficacy, and the neurophysiology of conversion disorder

Three papers of special interest to researchers and clinicians alike have recently appeared in the general scientific and medical literatures. Two of these papers are original research studies that employ brain-imaging technologies, one using Magnetic Resonance Imaging (MRI), the other position emission tomography (PET). A third paper is a comprehensive review of the empirical findings on the clinical use of hypnosis in pediatric oncology. The research study using MRI technology is extraordinary, because it is the first to document differences in brain morphology between high hypnotizable and low hypnotizable individuals. Arguably, if its findings replicate, the study could be one of the most important developments in scientific hypnosis since the genesis of the Stanford scales 45 years ago. The PET study notes differences in brain activation during intentionally simulated and hypnotically experienced paralysis. The review article examines empirical work addressing the efficacy of hypnosis for procedural pain in pediatric oncology.

Are there two qualitatively distinct forms of dissociation? A review and some clinical implications

This review aims to clarify the use of the term 'dissociation' in theory, research and clinical practice. Current psychiatric definitions of dissociation are contrasted with recent conceptualizations that have converged on a dichotomy between two qualitatively different phenomena: 'detachment' and 'compartmentalization'. We review some evidence for this distinction within the domains of phenomenology, factor analysis of self-report scales and experimental research. Available evidence supports the distinction but more controlled evaluations are needed. We conclude with recommendations for future research and clinical practice, proposing that using this dichotomy can lead to clearer case formulation and an improved choice of treatment strategy. Examples are provided within Depersonalization Disorder, Conversion Disorder and Posttraumatic Stress Disorder (PTSD).

Healing the disembodied mind: contemporary models of conversion disorder

The cartesian separation of body and mind has underpinned medical conceptualization of conversion symptoms over the last four centuries. Eighteenth- and nineteenth-century models explained conversion symptoms on the basis of assumed organic lesions. Subsequent psychological formulations focused on mental phenomena, which were disembodied from underlying neurobiological processes. Contemporary theories challenge this disconnection. They place conversion symptoms within an evolutionary framework, arguing that mind is embodied in physical processes and confers significant survival advantage. Current neurobiological models explain conversation symptoms as part of the human emotional response to threat, reflecting either errors in how information about body state is processes and represented, or the motor component of an automatic emotional response. Patients with conversion disorder experience their body functions in a range of distressing and disturbing ways. In order to understand these phenomena, clinicians require conceptual models that expand the conventional dualistic mind-body paradigm, integrate multiple theoretical perspectives, and take into account environmental factors that shape evolutionary and individual development.

Case study: camptocormia, a rare conversion disorder

Camptocormia is a condition characterized by severe frontal flexion of the spinal cord and knees, with passive drooping of both arms. It occurs as a form of conversion disorder. Some cases are associated with behavioral problems. A case of camptocormia of 2-year duration in a south Indian adolescent girl with oppositional defiant disorder and moderate mental retardation is reported.

Behavioural interventions in the rehabilitation of acute v. chronic non-organic (conversion/factitious) motor disorders

BACKGROUND

Repeated case series have documented the effectiveness of multidisciplinary in-patient behavioural treatment for conversion disorders. However, in the absence of controlled research, treatment success could be attributed to providing patients with a face-saving opportunity to get better.

AIMS

The present study contrasts two behavioural treatments to elucidate the factors underlying successful in-patient rehabilitation of this population.

METHOD

Thirty-nine patients underwent a standard behavioural programme. Using a crossover design, patients who did not improve underwent a strategic-behavioural treatment in which they and their families were told that full recovery constituted proof of an organic aetiology whereas failure to recover was definitive proof of a psychiatric aetiology.

RESULTS

Chart review indicated that the standard behavioural treatment was effective for 8/9 'acute' patients but only for 1/28 'chronic' patients. Of the 21 patients with chronic motor disorder who then under went the strategic-behavioural intervention, 13 were symptom-free at discharge.

CONCLUSIONS

The strategic intervention was superior to standard behavioural treatment for patients with chronic motor disorder. Treatment components previously deemed critical for the effectiveness of behavioural treatment may be unnecessary.

[Conversion disorders. From neurobiology to treatment]

The two international systems of diagnostic classification for psychiatric disorders, ICD-10 and DSM-IV, differentiate a variety of disorders or syndromes characterized by the common feature of the presence of physical symptoms without "organic correlate." Conversion disorders (DSM) or dissociative disorders (ICD) are historically related to the concept of hysteria. Like psychoanalytical theories, the DSM and ICD refer to a psychological conflict preceding the onset of physical symptoms, although in a purely descriptive manner. The etiology of these disorders is still not very well understood. This article summarizes present knowledge from clinical and epidemiological studies. Functional neuroimaging studies on conversion disorders, although still very rare, allow testing of hypotheses about neuronal mechanisms. Such studies question the traditional and often misinterpreted dichotomy between organic and psychogenic diseases.

Motor conversion disorders reviewed from a neuropsychiatric perspective

BACKGROUND

Conversion disorder is a somatoform disorder defined by the presence of pseudoneurologic symptoms relating to voluntary sensory or motor function. The correct diagnosis of conversion disorder presenting with motor symptoms is complicated by the lack of gold-standard diagnostic tests and the absence of a universally accepted set of positive diagnostic criteria. This article reviews the epidemiology, pathophysiology, presentation, differential diagnosis, treatment, and prognosis of motor conversion, placing emphasis on diagnostic validity, reliability, and utility, while evaluating the empirical evidence supporting diagnostic and treatment strategies.

DATA SOURCES AND STUDY SELECTION

Literature searches were carried out in PubMed using the keywords conversion disorder, motor conversion, dystonia, psychogenic, hysteria, somatization, motion disorder, movement disorder, and patho-physiology. Articles and book chapters in the author's personal collection were also utilized.

CONCLUSIONS

Advances in neuropsychiatric research are leading to significant improvements in the diagnosis and understanding of motor conversion disorders. Positive, objective, and quantitative diagnostic criteria show significant promise for enhancing diagnostic accuracy. Current pathophysiologic research has begun to provide mechanistic explanations for conversion symptoms, thus blurring the distinction between psychogenic and organic motor disorders.

The Treatment of Nonepileptic Seizures: Historical Perspectives and Future Directions

Nonepileptic seizures (NES) are neuropsychiatric disorders presenting with a combination of neurologic signs and underlying psychological conflicts. For more than a century, the medical community has accumulated data and insights about the phenomenology, epidemiology, risks, comorbidities, and prognosis of NES. However, we have not progressed much beyond anecdotal reports of treatments for NES, and no randomized, controlled trials of treatment for the disorder have been conducted. We review the diagnosis and treatment of NES and suggest directions for future research in these areas.

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: somatization and other somatoform disorders

This article reviews current knowledge about somatoform disorders in children and adolescents. Somatoform disorders are likely to occur more frequently in children and adolescents who have been severely maltreated than in others. The symptoms of somatoform disorders are reviewed, strategies for distinguishing somatoform disorders from other disorders are examined, and treatment strategies are explored.