"Conversion reactions" in adolescents: a biofeedback-based operant approach

Physical treatment of functional neurologic disorders

Physical interventions are widely considered an important part of treatment of functional neurologic disorders (FNDs). The evidence base for physical interventions has been limited to a collection of case series, but the recent publication of several large cohort studies and a randomized controlled trial have provided stronger evidence to support its use. While the evidence for efficacy appears to be promising, details on how this should be delivered remain limited, perhaps due to the dominance of psychologically focused etiologic models. A move towards understanding how the symptoms of FND are generated on a neurobiologic level has resulted in an expansion of pathophysiologic models providing a clearer rationale for physical treatment. In this context, the motor symptoms of FND can be considered as learnt patterns of movement, driven by attention and belief. Physical treatment aims to retrain movement by redirecting attention and addressing unhelpful illness beliefs and behaviors. The patient's problems should be considered in a broad biopsychosocial framework where symptom-predisposing, precipitating, and perpetuating factors can be addressed within a multidisciplinary environment as a gold standard. Further research is required to refine interventions and create evidence-based treatment guidelines.

Psychologic theories in functional neurologic disorders

In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.

Physiotherapy for functional (psychogenic) motor symptoms: a systematic review

OBJECTIVE

Functional (psychogenic) motor symptoms (FMS), also called motor conversion disorder or non-organic motor symptoms are a common cause of disability and distress among patients attending neurology and neurorehabilitation services. Patients with FMS are often referred for physiotherapy but it is not clear whether this is effective. Here we aim to systematically review the literature regarding physiotherapy interventions for patients with functional motor symptoms.

METHODS

Systematic review of databases with reference search for period 1950 to September 2012.

RESULTS

There was only one controlled intervention study with a historical control group and 28 case series or reports describing interventions. The total number of patients in all studies was 373. Physiotherapy most commonly occurred in the context of multidisciplinary treatment and involved a motor learning approach. Novel approaches included the use of distraction techniques and transcutaneous electrical nerve stimulation (TENS) machine. Deceptive behavioural techniques have also been described. Most studies reported benefit from physical treatment, including some studies with long-term follow up.

CONCLUSIONS

Patients with FMS are commonly encountered in neurological practice and are often referred for physiotherapy. The existing data to guide physiotherapy treatment for FMS is of low quality and limited in scope. However, it suggests potential positive effects and provides a useful resource for developing and testing physiotherapy interventions in future studies.

A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type

BACKGROUND

The primary aim of this study was threefold: (1) to examine the additional effects of hypnosis aimed at symptom reduction, using symptom-oriented and expression- and insight-oriented techniques in a comprehensive clinical treatment programme for in-patients with a persistent conversion disorder of the motor type; (2) to assess whether the level of hypnotisability was predictive of treatment outcome, and (3) to explore the efficacy of the total clinical treatment programme.

METHODS

The study population consisted of 45 in-patients between 18 and 65 years of age meeting the DSM-III-R criteria for conversion disorder of the motor type or somatisation disorder with motor conversion symptoms. A randomised controlled clinical trial was undertaken. The primary outcome measures were the Video Rating Scale for Motor Conversion Symptoms, the D(isabilities) code items from the International Classification of Impairments, Disabilities and Handicaps and the Symptom Checklist-90. Measures of the credibility of treatment and patient expectations of treatment outcome were used as manipulation checks. Hypnotisability was measured using the Stanford Hypnotic Clinical Scale.

RESULTS

Significant treatment results for all outcome measures were found for the total sample. These effects proved to be clinically significant. The use of hypnosis had no additional effect on treatment outcome. Hypnotisability was not predictive of treatment outcome.

CONCLUSION

A comprehensive treatment programme, either with or without hypnosis, can be worthwhile for patients with long-standing conversion symptoms.

A management model for pediatric somatization

Medically unexplained physical symptoms are common in pediatric settings, though little systematic research is available to guide the development of treatment efforts for pediatric somatization and somatoform disorders. This paper presents a management model for pediatric somatization based on principles distilled from the available pediatric and adult literature. Careful assessment, frank presentation of the diagnosis, and a cognitive-behavioral and rehabilitative approach are emphasized, along with aggressive psychiatric treatment of comorbid psychopathology. Well-designed empirical studies of intervention are needed that should examine efficacy as well as the relationship between symptomatic improvement, functional improvement, and comorbid anxiety and depressive symptoms.

Case study: negative reinforcement and behavioral management of conversion disorder

Behavioral interventions have been advocated for conversion disorder, but controlled trials are lacking. The authors report the case of a 12-year-old boy with conversion disorder after 3 months of persistent right arm pain and immobility whose symptoms rapidly resolved after an outpatient behavioral intervention using negative reinforcement. The importance of careful assessment, frank discussion of the diagnosis, patient and family psychoeducation, and a rehabilitative mindset are emphasized. Negative reinforcement may be a powerful tool in the management of pediatric conversion disorder, with the potential to reduce parental anxiety and prevent unnecessary physical assessments and interventions.

The inpatient treatment of patients suffering from (motor) conversion symptoms: a description of eight cases

This article presents a preliminary study that used two controlled randomized trials to study the effect of hypnosis in the treatment of eight patients with (motor) conversion symptoms. Controlled research into the treatment of conversion symptoms is scarce and can often be criticized on methodological grounds. It would appear, however, that both the use of suggestive and behavioral therapeutic techniques and eclectic treatment programs yield good results in the treatment of conversion symptoms. The results of the study suggest that comprehensive clinical treatment including hypnosis has enough promise to be studied in clinical trials. In the interpretation of the results, special attention is given to primary diagnosis, duration of complaints, traumatic experiences in childhood, dissociative capacity, and hypnotizability.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.