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.

Abnormal somatosensory evoked potentials in two patients with conversion disorder

On clinical grounds, somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) are currently used to discriminate between hysterical and neurological conditions. The present paper reports on two patients with severe gait disturbance who had the near-total absence of SEP responses on the scalp during the symptomatic period, which normalized after recovery. These findings, along with others, may shed light on the brain correlates of conversion phenomena.

Role of imaginary companion in promoting the psychotherapeutic process

An imaginary companion (IC) has been considered to be a transitory phenomenon sometimes seen in the normal developmental process of children. In recent years, however, it has been observed that ICs are related to various disorders, and their clinical significance is again attracting notice. Although an IC may in certain ways aggravate the patient's symptoms and regression, an IC may also serve to advance the therapy, for example by indicating the location of the patient's troubles, or acting as an intermediary between the therapist and patient. In cases of dissociative (conversion) disorders, it is generally difficult for patients to verbalize their troubles, but the present patients gained insight into themselves by closely examining their ICs. Imaginary companions are not simply entities incidental to the disorder, and by incorporating them into the therapeutic strategy as a presence supporting the patient's growth, it is possible that the psychotherapy may proceed more smoothly.

Somatization and conversion disorder

Somatization is the psychological mechanism whereby psychological distress is expressed in the form of physical symptoms. The psychological distress in somatization is most commonly caused by a mood disorder that threatens mental stability. Conversion disorder occurs when the somatic presentation involves any aspect of the central nervous system over which voluntary control is exercised. Conversion reactions represent fixed ideas about neurologic malfunction that are consciously enacted, resulting in psychogenic neurologic deficits. Treatment is complex and lengthy; it includes recovery of neurologic function aided by narcoanalysis and identification and treatment of the primary psychiatric disorder, usually a mood disorder.

Cognitive behavioural and neuropsychiatric treatment of post‐traumatic conversion disorder: a case study

Conversion disorder consists of involuntary sensory or motor symptoms and deficits that cannot be explained by a general medical condition. There are several treatment options, although none has emerged as the treatment of choice. The present case study examined the effects of adding cognitive behaviour therapy to neuropsychiatric management of conversion disorder (motor subtype). The patient, a retired emergency services worker, presented with a history of intermittent episodes of speech disruption (inability to speak or difficulty speaking properly). Although episodes of speech disturbance sometimes occurred unexpectedly, they were more likely to occur under conditions of stress and fatigue, and were triggered by reminders of work-related traumatic events. The patient was treated with pharmacotherapy and psychoeducation from a neuropsychiatrist. With the aim of improving treatment outcome, cognitive behaviour therapy was added, involving imaginal exposure to trauma memories, along with cognitive restructuring. The frequency of between- and within-session speech disturbance episodes declined over the course of cognitive behaviour therapy to the point that the patient was essentially symptom-free. Within-session distress ratings also decreased, which suggested habituation to trauma-related memories. This case study demonstrates how particular cognitive behaviour therapy interventions can be usefully applied to one form of conversion disorder.

Somatization and conversion: distinct or overlapping constructs?

The terms somatization and conversion are used descriptively to define specific diagnostic entities, and phenomenologically to denote pathologic processes that underlie somatic symptom formation. There is a lack of clarity, and even controversy, however, as to whether somatization and conversion should be considered distinct or overlapping constructs, and whether they contribute to the pathogenesis of certain organic diseases or solely to medically unexplained somatic symptoms. This article attempts to resolve some of this confusion by reviewing the origins of the terms somatization and conversion, and describing how their meanings and uses have evolved over the last century. Whereas some psychoanalysts and psychiatrists adopted Stekel's view that somatization involves a psychological process analogous to conversion, others maintained Freud's distinction between the psychoneuroses and the actual neuroses and view somatization as a physiological process. Recent psychoanalytic attempts to understand somatization are based on a modern theory of emotional processing, which is rooted in cognitive science and open to empirical research. Maintaining a conceptual distinction between somatization and conversion has important implications for psychoanalytic therapy.

Cognitive-behavioral therapy of conversion aphonia

Although a common disease, conversion disorder still calls attention in the clinical practice. A case of conversion disorder, diagnosed as a psychogenic aphonia that persisted for a week, was reported in this paper. A 21-year-old woman developed symptoms after breaking off a long-lasting relationship with her boy-friend. History revealed that she was introvert with high neuroticism and communication problems. Cognitive-behavioral therapy was used. After the positive reinforcement in the therapy of her aphonia, assertion training for the development of communication skills was performed. In the end, cognitive restructuring was used to prevent relapse in regard to her actual life situation of being a refugee preparing for immigration to Australia.

Globus hystericus: a brief review

Globus hystericus, a form of conversion disorder, is characterized by an uncomfortable sensation of a mass in the esophagus or airway. Evaluation proves no mass exists. Anxiety or psychological conflict is judged to be significantly related to the onset and progression of the sensation. The sensation may lead to difficulty swallowing or breathing and may become severe or life threatening. The disorder is poorly studied and understood. The differential diagnosis is vast. Management of the disorder is similar to that suggested for other conversion disorders. This article reviews the current literature about diagnosis, etiology, treatment, and prognosis of globus hystericus.

[Hysterical symptoms and the body in old age]

The psychological significance of the body changes in the course of a person's life. Using clinical cases it was examined how conversion symptoms influence these changes. Elder patients having conversion symptoms hardly perceive the aging processes of the body. Based on the assumption that the body self develops in the course of a life through internalization processes and that the body scheme is influenced and becomes more concrete through cognitive processes (e.g. experiences with illness) the body self and the body scheme become increasingly separate. The conversion with pseudoneurological symptoms is characterized by the cognitively perceived body image, the body scheme, through which normally also the aging processes become conscious. Since the conversion requires the body scheme to portray psychic conflicts the somatogenic organization function (Heuft) is repealed and as a result the aging processes of the body and therefore aging are not dealt with adequately.

Paradoxical therapy in conversion reaction

Paradoxical therapy consists of suggesting that the patient intentionally engages in the unwanted behaviour such as performing compulsive ritual or wanting a conversion attack. In this study, the subjects were selected by the emergency unit psychiatrist from patients who were admitted to the emergency unit with pseudoseizure. The diagnoses was based on DSM-IV criteria. Paradoxical intention was applied to half of the 30 patients with conversion disorders; the other half were treated with diazepam in order to examine the efficiency of the paradoxical intention versus diazepam. In both groups the differences of the anxiety scores at the beginning of the study were found to be insignificant (z=1.08, p=0.28). Of the 15 patients who completed paradoxical intention treatment, 14 (93.3%) responded favorably to paradoxical intention. On the other hand of 15 patients who completed diazepam therapy, 9 (60%) responded well to therapy and 6 patients carried on their conversion symptoms at the end of 6 weeks. Paradoxical intention-treated patients appeared to have greater improvements in anxiety scores (z=2.43, p<0.015) and conversion symptoms (t=2.27, p=0.034) than the diazepam-treated patients. The results of the present study are encouraging in that paradoxical intention can be effective in the treatment of conversion disorder.

The 12 year prognosis of unilateral functional weakness and sensory disturbance

BACKGROUND

Although the symptoms of unilateral "medically unexplained" or "functional" weakness and sensory disturbance present commonly to neurologists, little is known about their long term prognosis.

OBJECTIVE

To determine the long term outcome of functional weakness and sensory disturbance.

PATIENTS

A previously assembled cohort of 60 patients seen as inpatients by consultant neurologists in Edinburgh between 1985 and 1992 and diagnosed as having unilateral functional weakness or sensory disturbance.

METHODS

Current symptoms, disability, and distress were assessed by postal questionnaire to the patients and their family doctors.

RESULTS

Follow up data relating to mortality were obtained in 56 patients (93%) and to current diagnosis in 48 patients (80%). Patient questionnaire data were obtained in 42 patients (70%). The median duration of follow up was 12.5 years (range 9 to 16). Thirty five of the 42 patients (83%) still reported weakness or sensory symptoms, and the majority reported limitation of physical function, distress, and multiple other somatic symptoms. Twenty nine per cent had taken medical retirement. An examination of baseline predictors indicated that patients who had sensory symptoms had better functioning at follow up than those who had weakness. Only one patient had developed a neurological disorder which, in hindsight, explained the original presentation. Another patient had died of unrelated causes.

CONCLUSIONS

Many patients assessed by neurologists with unilateral functional weakness and sensory symptoms as inpatients remain symptomatic, distressed, and disabled as long as 12 years after the original diagnosis. These symptoms are only rarely explained by the subsequent development of a recognisable neurological disorder in the long term.

[A child whose parents denied her psychiatric care]

A 15-year-old girl was admitted because of an abdominal tumour and inability to eat. History revealed that after an accident at 9 years of age she increasingly developed medically unexplained signs and symptoms (e.g. tunnel vision with blindness, paralysis and loss of sensitivity below the umbilicus, periods of diminished consciousness). No somatic explanation could be found; the parents rejected psychiatric examination. Upon physical examination the patient's weight's was far below the third percentile (32 kg) and the tumour appeared to be the lumbar spine, palpable through the abdominal wall. Following tube feeding and behavioural therapy the girl gained weight and the tumour disappeared. No cause for the underweight was found. Conversion disorder was diagnosed. However, the parents strongly refused to accept this diagnosis; they lodged complaints with various bodies and made further treatment and counseling impossible. Children with psychological problems who were treated as having a somatic disorder by their mothers have been described before. The outcome can be lethal. Children showing unexplained signs and symptoms whose parents strongly refuse psychiatric care will be seriously jeopardised in terms of their somatic and psychological development. Physicians should identify this situation at an early stage.

A randomized controlled clinical trial of a hypnosis-based treatment for patients with conversion disorder, motor type

This study tested whether a hypnosis-based intervention showed promise as a treatment for patients with conversion disorder, motor type. Forty-four outpatients with conversion disorder, motor type, or somatization disorder with motor conversion symptoms, were randomly assigned to a hypnosis or a waiting-list condition. The hypnosis-condition patients were more improved relative to baseline and the waiting-list controls. Improvement was evident on an observational index of behavioral symptoms associated with the motor conversion and on an interview measure of extent of motor disability. No effect was obtained on a nonspecific measure of broad psychopathology immediately posttreatment. At 6-month follow-up, improvement was maintained across the behavioral and interview measures. The effect size of hypnotizability as a predictor of treatment outcome was comparable to that found for other individual patient differences associated with psychotherapy outcome although non-significant. Hypnotizability scored above patient expectations as a predictor of treatment outcome.

Three core hypnotic phenomena studied with both scientific precision and clinical savvy

Three especially interesting and important studies on hypnosis have appeared in the scientific and medical literatures over the past few months. They are in the finest tradition of the field. Each study examines a phenomenon that is at once core to scientific hypnosis but also of keen interest to clinicians: conversion disorder, amnesia, and pain. It is testimony to the vigor of the field that these 3 phenomena endure as topics of discourse within and across disciplines. Further, the 3 studies make use of sophisticated designs and methodologies to render findings more (not less) relevant to clinical work. These 3 studies are wonderful examples of the field at its best: eschewing the partisan, embracing discourse, and in so doing mapping the domain of hypnosis with imagination and passion.

[An unusual case of non-structural scoliosis (case report)]

The case of a female patient with conversion scoliosis is described. At 24 years, the patient underwent surgery for herniated disks in the L4-L5 and L5-S1 regions and a short-time relief was achieved. At age 28, she was admitted to our department because of severe pain and antalgic posture. Because radiographs of her spine showed no findings corresponding to her symptoms, psychological examination was indicated. This revealed traumatic emotional experience in her family of origin and later also in her foster family, which unfavorably affected her married life. Psychotherapy, including cognitive behavioral treatment, hypnotherapy and audiovisual stimulation, markedly improved the patient's mental and somatic state during two periods of hospitalization. The effects of psychotherapy, physical therapy and adaptation of her physical activity regimen were still evident at 1 year after her therapy was commenced.

Conversion disorder after implant of a spinal cord stimulator in a patient with a complex regional pain syndrome

IMPLICATIONS

This case history describes the treatment of a patient suffering with persistent pain. He was treated surgically with implantation of a spinal cord stimulator. After surgery, a partial paralysis that could not be explained medically and that was probably related to emotional factors occurred, and cognitive behavioral treatment was begun. This paper discusses the importance of considering social and psychological factors when medical treatment options are considered.