[Conversion disorders in children and adolescents. A multidisciplinary approach]

Conversion disorders are characterized by change or loss of physical functions which indicates a neurological disorder (e.g. paralysis, sensory disturbances, or epilepsy like seizures). Clinical/neurological examination does not confirm any organic basis for the symptoms. Conversion disorders are more frequent in girls than in boys. They are rarely seen below the age of seven. A correspondence is often found between the personality of the child, (a conscientious attitude) and family relations. The families seem quite normal, but often have high expectations of their children, are sensitive to social stigmatization and have an underlying anxiety for health problems. A model is often found for the child's symptoms. Symptoms may be precipitated by an infection or a physical trauma. Sexual abuse is sometimes discovered. Multiprofessional assessment and treatment by a neuropediatrician, physiotherapist, child psychiatrist/psychologist and educational therapist may reduce "doctor shopping" and contribute to a favourable outcome.

Psychogenic stridor

In the past 20 years, several cases have been reported describing an upper airway obstruction reportedly caused by psychological factors. This paper reviews 48 reported cases of "psychogenic stridor." Patients with psychogenic stridor usually present to primary care physicians with symptoms of asthma or stridor unresponsive to conventional treatments. Of the 48 cases reviewed, 52% received a diagnosis of conversion disorder. The obstruction was severe enough to cause intubation and tracheostomies in some patients. In addition, many suffered from the unnecessary side effects of corticosteroids. The literature is reviewed and medical and psychiatric differential diagnosis and treatment are discussed.

Familial psychogenic blindness and headache: a case study

BACKGROUND

Amaurosis is an uncommon conversion phenomenon, which to our knowledge has never been reported in multiple family members.

METHOD

A man and his two adult children, all afflicted with periods of blindness and accompanying severe headaches for varying periods of time (days to years), were examined and extensively studied radiologically and with multiple laboratory tests.

RESULTS

In all three individuals, no evidence of organic disease was found; all three recovered to varying degrees, usually after suggestion.

CONCLUSION

Psychogenic amaurosis with headaches can simulate migraine; the mechanism for occurrence in a family is probably similar to that of mass hysteria.

Treatment of hysterical aphonia with hypnosis and prokaletic therapy

A patient with chronic refractory hysterical aphonia was treated by prokalesis (challenge) and hypnosis within a psychotherapeutic relationship. A temporary remission was achieved but this was followed by subsequent relapse. This report illustrates the therapeutic effectiveness of prokaletic techniques. It also emphasises that these potent interventions are unlikely to achieve abiding change unless they are applied within the context of a longer-term relationship with a clinical team.

[Existential analytic psychotherapy of conversion neurosis in migrant workers]

After a brief introduction into some existential-analytic points of view of the body and of conversion syndrome the actual socio-cultural situation of the migrant workers is explained with many details. For the understanding of the meaning of the conversion symptoms it is necessary to search for the existential concept of the patient which is actually in danger. The therapeutic procedure following this concept is demonstrated on the base of four clinical cases.

Hypnotherapy and contractures of the hand

Contractures of the hand are rather uncommon conversion phenomena. As yet, very little is known about treatment. After a brief overview of the literature on the various treatment strategies, we describe the treatment of four patients. There are indications that a complaint-centered approach, which attempts to influence the symptom directly, produces positive results. Hypnotherapeutic techniques were used in the four patients described here. Treatment resulted in improvement in three of the four.

When neurological symptoms are not what they appear: the challenge of caring for patients with conversion disorders

Conversion Disorders involve the psychogenic loss or disturbance of sensory, motor or other physical functions in a manner suggestive of neurologic or other somatic disease but without any actual finding of the latter. These problems are subconscious, with patients not being able to control their symptoms. Jean-Marie Charcot, in the 19th century, was fascinated with this disorder and his work, followed by that of Sigmund Freud, laid the foundation for our modern concept of Conversion Disorder. Multiple Sclerosis, with its fluctuating and unpredictable symptoms has frequently been erroneously diagnosed in these cases. The often bizarre, flamboyant presentations, while interesting, pose many difficult and complex management problems. This paper will describe three of the more severe and disabled examples of this condition seen in the London Multiple Sclerosis Clinic and an attempt will be made to uncover common patient characteristics. Current thoughts regarding the management of these patients will be outlined, the emphasis being on helping neuroscience nurses develop an approach which is informed, positive and compassionate.

Conversion deafness

Conversion deafness is very rarely encountered among adults. This report will illustrate two cases of this somatoform disorder following different traumatic experiences. It emphasizes the difficulties in establishing the diagnosis and reviews various aspects of treatment.

[Somnambulism and pavor nocturnus--review and case report]

A case of night terror with sleepwalking in an adult patient is described. Sleep polygraphic data are presented. The literature related to sleepwalking, night terror and its treatment is reviewed. The psychopathologic patterns of sleepwalking and night terror are illustrated and the differentiations of parasomnias and epileptic seizures discussed. The clinical applications of these findings are described and practical recommendations made for the management of NON-REM parasomnia.

[Psychogenic aphonia; an effective and rapidly treatable conversion]

Psychogenic aphonia is a conversion symptom which is quite annoying to the patient. This article concentrates on the treatment of psychogenic aphonia. The literature contains only few articles on this subject. We present in detail a very efficient way of treatment with directive and biofeedback aspects. Central to the treatment is a direct approach of the symptom, based on the idea that due to the time factor the aphonia has become dissociated from the unconscious psychological conflict. The treatment starts with a double cough so that the vocal chords close. At the same time the ear, nose and throat specialist looks with the laryngoscope and corrects directly which gives an optimal learning effect. In 1988 and 1989, 23 patients were treated with this method. The duration of the aphonia varied from two weeks to two years. In eight of the patients the aphonia recurred. Patients were treated for a total of 45 episodes of aphonia. In all cases the voice returned within an hour.

Differential diagnosis and treatment of conversion disorder and Guillain-Barre syndrome

Three cases are presented which illustrate the possible difficulties in differentiating between the diagnoses of Guillain-Barre Syndrome and conversion disorder. Accepted criteria are specified for each condition, as well as some associated features often characteristic of similar cases. Supportive interdisciplinary treatment for Guillain-Barre Syndrome is reviewed, and an interdisciplinary multi-modal approach to treatment of conversion disorder is described.

Short-term strategic treatment in traumatic conversion reactions

The therapists applied the strategic approach in four cases that demonstrate a variety of traumatic and conversion reactions. The therapists accepted the definition of the problem as presented by the patients or their families at the overt level, and were able to treat the conversion symptoms. At the latent level, however, there were additional system-focused goals. In the first stage, the therapists strove to understand the inner world and cultural background of their patients, their dynamics and the circumstances surrounding the event that led to the conversion reaction, or the traumatic significance of the event when it was a posttraumatic conversion. It was then possible to develop a strategy for treatment and to decide which treatment techniques were appropriate. The therapists created situations that encouraged change and pushed the patients to abandon the symptom. This therapy model is composed of behavioral and paradoxical techniques based on the understanding of the dynamic material and cultural content.

[A case of conversion disorder analyzed from a psychodynamic, psychophysiologic, and morphodynamic perspective]

This paper presents a case of conversion disorder characterized by sensory paralysis that involved the right half of the body, a motor deficit consisting of permanent contracture in flexion of fingers 2-5 of the right hand (clenched fist syndrome), and a visual alteration compatible with homonymous hemianopia and amblyopia. The patient initially presented a clinical picture of depression as well as frequent gynecological disorders. The author evaluates important aspects of the psychogenesis of the clinical picture and emphasizes the identifying aspects and primary and secondary gains. Consideration is given to the distinct therapeutic strategies used (psychotherapy, autogenous training, hypnosis), and the case is analyzed from a morphodynamic point of view. The author concludes that the organic basis of the clinical picture would be localized in the posterior nuclei of the thalamus.

The persistence of symptoms in patients with globus pharyngis

A follow-up study of 104 patients with globus sensation was performed by postal questionnaire. All were asked to complete the Eysenck Personality Questionnaire (EPQ) and a 12-item Throat Symptom Questionnaire. Seventy-two of these patients were sent a follow-up General Health Questionnaire (GHQ). Replies were received from 89 patients (86%), 68 females and 21 males, a mean of 31 months after initial presentation. The feeling of something stuck in the throat had disappeared completely in 27% of patients, but only 4% were never aware of the throat. Throat symptoms showed a reduction with increasing age, but not with increasing interval since presentation. The 15 patients initially treated with antacid therapy had significantly greater dyspepsia scores at review than untreated patients, but no other difference was found between the two groups. GHQ scores showed a small but significant reduction over time. Of EPQ parameters, only the lower lie score in female patients showed any significant difference on repeat testing. Those with persistently high throat scores had significantly lower EPQ lie scores and a trend towards higher GHQ scores at follow-up. None of the psychological parameters measured at the first interview was found to be of prognostic significance. We conclude that, although there is a reduction in occult psychiatric morbidity in patients with the globus sensation over time, underlying personality traits remain stable and that there is a remarkable persistence of pharyngeal symptoms.

Two unusual gait disturbances: astasia abasia and camptocormia

The physiatrist frequently encounters gait abnormalities in his daily practice. Commonly, there is an obvious organic basis for the disturbance. However, on rare occasions, the gait abnormality is the consequence of a functional conversion reaction. This represents both a diagnostic and therapeutic dilemma, in extreme cases leading to unnecessary diagnostic tests and their associated complications and costs. Early suspicion and knowledge of functional gait disorders may expedite the correct diagnosis and the institution of appropriate therapy, shortening hospital stay and eliminating unnecessary procedures. This case study reviews two patients with unique gait disturbances-astasia abasia and camptocormia. Astasia abasia is the inability to stand or walk in the absence of other neurologic abnormalities. Camptocormia is characterized by exaggerated trunk flexion of functional etiology. Both patients demonstrated rapid resolution of symptoms after psychiatric intervention.