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Carle-Toulemonde G, Goutte J, Do-Quang-Cantagrel N, Mouchabac S, Joly C, Garcin B. Overall comorbidities in functional neurological disorder: A narrative review. L'ENCEPHALE 2023:S0013-7006(23)00086-6. [PMID: 37414721 DOI: 10.1016/j.encep.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION The importance to assess and include the frequent comorbidities in the personalised care management plan of patients with functional neurological disorders (FND) has arisen through the years. FND patients are not only complaining from motor and/or sensory symptoms. They also report some non-specific symptoms that participate to the burden of FND. In this narrative review, we aim to better describe these comorbidities in terms of prevalence, clinical characteristics and their variability depending on the subtype of FND. METHODS The literature was searched for on Medline and PubMed. The search was narrowed to articles between 2000 and 2022. RESULTS Fatigue is the most common symptom reported in relation to FND (from 47 to 93%), followed by cognitive symptoms (from 80 to 85%). Psychiatric disorders are reported in 40 to 100% FND patients, depending on the FND subtype (functional motor disorder [FMD], functional dissociative seizures [FDS]…) but also on the type of psychiatric disorder (anxiety disorders being the most frequent, followed by mood disorders and neurodevelopmental disorders). Stress factors such as childhood trauma exposure (emotional neglect and physical abuse predominantly) have also been identified in up to 75% of FND patients, along with maladaptive coping strategies. Organic disorders are commonly reported in FND, such as neurological disorders (including epilepsy in FDS [20%] and FMD in Parkinson's Disease [7%]). Somatic symptom disorders including chronic pain syndromes are frequently associated to FND (about 50%). To be noted, recent data also suggest a high comorbidity between FND and hypermobile Ehlers Danlos Syndrome (about 55%). CONCLUSION Put together, this narrative review highlights the high burden of FND patients, not only due to somatosensory alterations but also by considering the frequent comorbidities reported. Thus, such comorbidities must be taken into consideration when defining the FND personalised care management strategy for the patients.
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Affiliation(s)
| | - Julie Goutte
- Internal Medicine Department, Saint-Etienne University Hospital, Saint-Priest-en-Jarez, France
| | | | - Stéphane Mouchabac
- Sorbonne University, Department of Psychiatry, AP-HP, Saint-Antoine University Hospital, Paris, France
| | - Charlotte Joly
- Neurology Department, Assistance Publique-Hôpitaux de Paris, AP-HP Avicenne University Hospital, Bobigny, France
| | - Béatrice Garcin
- Neurology Department, Assistance Publique-Hôpitaux de Paris, AP-HP Avicenne University Hospital, Bobigny, France
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Campbell MC, Smakowski A, Rojas-Aguiluz M, Goldstein LH, Cardeña E, Nicholson TR, Reinders AATS, Pick S. Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis. BJPsych Open 2022; 9:e2. [PMID: 36451595 PMCID: PMC9798224 DOI: 10.1192/bjo.2022.597] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Studies have reported elevated rates of dissociative symptoms and comorbid dissociative disorders in functional neurological disorder (FND); however, a comprehensive review is lacking. AIMS To systematically review the severity of dissociative symptoms and prevalence of comorbid dissociative disorders in FND and summarise their biological and clinical associations. METHOD We searched Embase, PsycInfo and MEDLINE up to June 2021, combining terms for FND and dissociation. Studies were eligible if reporting dissociative symptom scores or rates of comorbid dissociative disorder in FND samples. Risk of bias was appraised using modified Newcastle-Ottawa criteria. The findings were synthesised qualitatively and dissociative symptom scores were included in a meta-analysis (PROSPERO CRD42020173263). RESULTS Seventy-five studies were eligible (FND n = 3940; control n = 3073), most commonly prospective case-control studies (k = 54). Dissociative disorders were frequently comorbid in FND. Psychoform dissociation was elevated in FND compared with healthy (g = 0.90, 95% CI 0.66-1.14, I2 = 70%) and neurological controls (g = 0.56, 95% CI 0.19-0.92, I2 = 67%). Greater psychoform dissociation was observed in FND samples with seizure symptoms versus healthy controls (g = 0.94, 95% CI 0.65-1.22, I2 = 42%) and FND samples with motor symptoms (g = 0.40, 95% CI -0.18 to 1.00, I2 = 54%). Somatoform dissociation was elevated in FND versus healthy controls (g = 1.80, 95% CI 1.25-2.34, I2 = 75%). Dissociation in FND was associated with more severe functional symptoms, worse quality of life and brain alterations. CONCLUSIONS Our findings highlight the potential clinical utility of assessing patients with FND for dissociative symptomatology. However, fewer studies investigated FND samples with motor symptoms and heterogeneity between studies and risk of bias were high. Rigorous investigation of the prevalence, features and mechanistic relevance of dissociation in FND is needed.
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Affiliation(s)
- Malcolm C Campbell
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK; and Central and North West London NHS Foundation Trust, London, UK
| | - Abigail Smakowski
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK; and University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maya Rojas-Aguiluz
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Laura H Goldstein
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Etzel Cardeña
- Center for Research on Consciousness and Anomalous Psychology (CERCAP), Department of Psychology, Lund University, Lund, Sweden
| | - Timothy R Nicholson
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | | | - Susannah Pick
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
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Torres ME, Löwe B, Schmitz S, Pienta JN, Van Der Feltz-Cornelis C, Fiedorowicz JG. Suicide and suicidality in somatic symptom and related disorders: A systematic review. J Psychosom Res 2021; 140:110290. [PMID: 33227556 PMCID: PMC7945369 DOI: 10.1016/j.jpsychores.2020.110290] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/28/2020] [Accepted: 11/07/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We sought to determine the frequency of and risk factors for suicide outcomes in somatic symptom and related disorders and whether any risk was independent of co-occurring mental disorders. METHODS We conducted a systematic review of studies on suicide death, suicide attempts, and suicidal ideation in those with somatic symptom disorders published prior to September 22, 2020 and indexed in PubMED, MEDLINE, PsycARTICLES, PsycINFO, EMBASE, or SCOPUS according to PRISMA guidelines. RESULTS Our search yielded 33 articles with significant heterogeneity in study design, sample selection, and assessment for suicide or risk factors. While suicide deaths have not been adequately studied, somatic symptom and related disorders are associated with increased risk for suicidal ideation and suicide attempts, with estimates ranging from 24 to 34% of participants who endorsed current active suicidal ideation and 13-67% of participants who endorsed a prior suicide attempt. The risk appeared independent of co-occurring mental disorders. Identified risk factors for suicide attempts in samples with somatic symptom and related disorders include scores on measures of anger, alexithymia, alcohol use, past hospitalizations, dissociation, and emotional abuse. CONCLUSION Although the literature is sparse, there exists evidence for an association, even independent of other mental disorders, between somatic symptom and related disorders and suicide outcomes. Practice guidelines for the management of these disorders should incorporate recommendations for the assessment and management of suicide risk. Future study is necessary to more fully elucidate potential unique risk factors for those suffering from these complex disorders.
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Affiliation(s)
| | - Bernd Löwe
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samantha Schmitz
- Florida Atlantic University, Boca Raton, FL, United States; Des Moines University, Des Moines, IA, United States
| | - John N Pienta
- University of Iowa Hospitals and Clinics, United States
| | | | - Jess G Fiedorowicz
- The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Maggio J, Alluri PR, Paredes-Echeverri S, Larson AG, Sojka P, Price BH, Aybek S, Perez DL. Briquet syndrome revisited: implications for functional neurological disorder. Brain Commun 2020; 2:fcaa156. [PMID: 33426523 PMCID: PMC7784044 DOI: 10.1093/braincomms/fcaa156] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022] Open
Abstract
With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on ‘rule-in’ physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. In addition, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioural (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and/or fatigue; the need for bodily symptoms to be ‘medically unexplained’ was removed, and the overall utility of this diagnostic criteria remains debated. A consequence of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition would benefit from an integrated diagnosis at this intersection. We seek to revisit this with modifications, particularly since pain (and a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder. As a first step, we systematically reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data. Thereafter, we propose a preliminary revision to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition allowing for the specifier functional neurological disorder ‘with prominent pain’. To meet this criterion, core functional neurological symptoms (e.g. limb weakness, gait difficulties, seizures, non-dermatomal sensory loss and/or blindness) would have ‘rule-in’ signs and pain (>6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioural (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of ‘with prominent pain’ is etiologically neutral, while secondary specifiers provide additional clarification. We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups—resulting in diagnostic, treatment and pathophysiology implications.
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Affiliation(s)
- Julie Maggio
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Priyanka R Alluri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Paredes-Echeverri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna G Larson
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Petr Sojka
- Department of Psychiatry, University Hospital Brno, Czech Republic
| | - Bruce H Price
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Selma Aybek
- Department of Neurology, Inselspital University Hospital Bern and Clinical Neurosciences Bern, Bern University, Switzerland
| | - David L Perez
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Structural alterations in functional neurological disorder and related conditions: a software and hardware problem? NEUROIMAGE-CLINICAL 2019; 22:101798. [PMID: 31146322 PMCID: PMC6484222 DOI: 10.1016/j.nicl.2019.101798] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023]
Abstract
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A “software” vs. “hardware” analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including “disease staging” discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a “software” and “hardware” problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder. Transdiagnostic systematic review of structural MRI studies in FND and SSD Sensorimotor-striatothalamic-limbic-paralimbic circuits implicated in both conditions. Some small sample size FND studies did not show group-level structural alterations. MRI alterations may relate to risk factors, compensatory changes or disease mechanisms. Early-phase discussion on disease-staging algorithms outlined as a future direction.
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Perez DL, Matin N, Williams B, Tanev K, Makris N, LaFrance WC, Dickerson BC. Cortical thickness alterations linked to somatoform and psychological dissociation in functional neurological disorders. Hum Brain Mapp 2017; 39:428-439. [PMID: 29080235 DOI: 10.1002/hbm.23853] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/21/2017] [Accepted: 10/10/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Links between dissociation and functional neurological disorder (FND)/conversion disorder are well-established, yet the pathophysiology of dissociation remains poorly understood. This MRI study investigated structural alterations associated with somatoform and psychological dissociation in FND. We hypothesized that multimodal, paralimbic cingulo-insular regions would relate to the severity of somatoform dissociation in patients with FND. METHODS FreeSurfer cortical thickness and subcortical volumetric analyses were performed in 26 patients with motor FND and 27 matched healthy controls. Patients with high dissociation as measured by the Somatoform Dissociation Questionnaire-20 (SDQ) or Dissociative Experiences Scale (DES) were compared to controls in stratified analyses. Within-group analyses were also performed with SDQ and DES scores in patients with FND. All cortical thickness analyses were whole-brain corrected at the cluster-wise level. RESULTS Patients with FND and high somatoform dissociation (SDQ > 35) showed reduced left caudal anterior cingulate cortex (ACC) cortical thickness compared to controls. In within-group analyses, SDQ scores inversely correlated with left caudal ACC cortical thickness in patients with FND. Depersonalization/derealization scores positively correlated with right lateral occipital cortical thickness. Both within-group findings remained statistically significant controlling for trait anxiety/depression, borderline personality disorder and post-traumatic stress disorder, adverse life events, and motor FND subtypes in post-hoc analyses. CONCLUSION Using complementary between-group and within-group analyses, an inverse association between somatoform dissociation and left caudal ACC cortical thickness was observed in patients with FND. A positive relationship was also appreciated between depersonalization/derealization severity and cortical thickness in visual association areas. These findings advance our neuropathobiological understanding of dissociation in FND. Hum Brain Mapp 39:428-439, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Nassim Matin
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kaloyan Tanev
- Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - Nikos Makris
- Center for Morphometric Analysis, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Rhode Island Hospital, Departments of Psychiatry and Neurology, Brown University, Alpert Medical School, Providence, Rhode Island
| | - Bradford C Dickerson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts.,Department of Neurology, Frontotemporal Disorders Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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[Suicide risk in somatoform disorders]. NEUROPSYCHIATRIE : KLINIK, DIAGNOSTIK, THERAPIE UND REHABILITATION : ORGAN DER GESELLSCHAFT ÖSTERREICHISCHER NERVENÄRZTE UND PSYCHIATER 2017; 32:9-17. [PMID: 28940150 DOI: 10.1007/s40211-017-0248-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The somatoform disorders include a group of complex disorders consist of somatic symptoms for which there are no identifiable organic cause or pathogenetic mechanisms. Given the importance of these disorders and the need to clarify the diagnosis of somatoform disorder affecting the suicide risk, we took into consideration the scientific literature to investigate the correlation between the two conditions. METHODS We performed a bibliographic search through Medline, Embase, PsycINFO, Scopus, SciELO, ORCID, Google Scholar, DOAJ using the following terms: somatoform, somatization disorder, pain disorder AND psychological factor, suicide, parasuicide, suicidality. RESULTS In all studies reported in our review, the suicidal behavior risk is high. But in the majority, the data are relatively unreliable because it takes into account the category nosographic "Neurotic, stress-related and somatoform disorders", too wide to be able to identify the clinical characteristics of patients at risk of only somatoform disorder. CONCLUSIONS Several studies conclude that psychiatric comorbidity increases the suicide risk: patients with two or more psychiatric disorders are more likely to commit a suicide attempt; in particular if there is a axis I diagnosis, the risk reduplicate. The somatization disorder seems to have a significant psychiatric comorbidity in particular with anxious and affective disorders spectrum.
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Barzegaran E, Carmeli C, Rossetti AO, Frackowiak RS, Knyazeva MG. Weakened functional connectivity in patients with psychogenic non-epileptic seizures (PNES) converges on basal ganglia. J Neurol Neurosurg Psychiatry 2016; 87:332-7. [PMID: 25855401 DOI: 10.1136/jnnp-2014-309483] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/14/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Psychogenic non-epileptic seizures (PNES) are involuntary paroxysmal events that are unaccompanied by epileptiform EEG discharges. We hypothesised that PNES are a disorder of distributed brain networks resulting from their functional disconnection.The disconnection may underlie a dissociation mechanism that weakens the influence of unconsciously presented traumatising information but exerts maladaptive effects leading to episodic failures of behavioural control manifested by psychogenic 'seizures'. METHODS To test this hypothesis, we compared functional connectivity (FC) derived from resting state high-density EEGs of 18 patients with PNES and 18 age-matched and gender-matched controls. To this end, the EEGs were transformed into source space using the local autoregressive average inverse solution. FC was estimated with a multivariate measure of lagged synchronisation in the θ, α and β frequency bands for 66 brain sites clustered into 18 regions. A multiple comparison permutation test was applied to deduce significant between-group differences in inter-regional and intraregional FC. RESULTS The significant effect of PNES-a decrease in lagged FC between the basal ganglia and limbic, prefrontal, temporal, parietal and occipital regions-was found in the α band. CONCLUSION We believe that this finding reveals a possible neurobiological substrate of PNES, which explains both attenuation of the effect of potentially disturbing mental representations and the occurrence of PNES episodes. By improving understanding of the aetiology of this condition, our results suggest a potential refinement of diagnostic criteria and management principles.
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Affiliation(s)
- Elham Barzegaran
- Laboratoire de Recherche en Neuroimagerie (LREN), Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Cristian Carmeli
- Laboratoire de Recherche en Neuroimagerie (LREN), Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland Bioinformatics Core Facility, Swiss Institute of Bioinformatics (SIB), Lausanne, Switzerland
| | - Andrea O Rossetti
- Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Richard S Frackowiak
- Laboratoire de Recherche en Neuroimagerie (LREN), Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Maria G Knyazeva
- Laboratoire de Recherche en Neuroimagerie (LREN), Département des Neurosciences Cliniques (DNC), Centre Hospitalier Universitaire Vaudois (CHUV), and University of Lausanne, Lausanne, Switzerland Départment de Radiologie, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Varalakshmi B, Doshi VV, Sivalingam D, Nambi S. The story of a girl with weeping blood: Childhood depression with a rare presentation. Indian J Psychiatry 2015; 57:88-90. [PMID: 25657464 PMCID: PMC4314924 DOI: 10.4103/0019-5545.148533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Ms. V, a 10-year-old girl was referred to Child Psychiatry Department with complaints of bleeding from eyes for last 3 months. Bleeding was spontaneous, recurrent, painless, and self-limited. History revealed significant Psychological stressors, Temperamental Difficulties and Conflicts with Mother. Mental status examination revealed Depression in Ms. V. During hospital stay, Ms. V developed repeated bleeding episodes. The presence of hemoglobin is confirmed in the bleeding sample. Hematologic investigations and computed tomography brain were normal. Ms. V was started on Sertraline, Propranolol, and Clonazepam. Both Ms. V and her Mother were psycho-educated about the nature of the illness. Ms. V was discharged and under follow-up. This case is reported for the rarity of presentation (bleeding from Eyes) of a childhood Depression.
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Affiliation(s)
- B Varalakshmi
- Department of Psychiatry, Institute of Mental Health, Madras Medical College, Chennai, Tamil Nadu, India
| | - V Vimal Doshi
- Department of Psychiatry, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - D Sivalingam
- Department of Psychiatry, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Shanthi Nambi
- Department of Psychiatry, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
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Li R, Liu K, Ma X, Li Z, Duan X, An D, Gong Q, Zhou D, Chen H. Altered Functional Connectivity Patterns of the Insular Subregions in Psychogenic Nonepileptic Seizures. Brain Topogr 2014; 28:636-45. [PMID: 25352166 DOI: 10.1007/s10548-014-0413-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/20/2014] [Indexed: 10/24/2022]
Abstract
Neuroimaging studies have demonstrated that psychogenic nonepileptic seizures (PNES) are characterized by unstable cognitive-emotional and motor system, which is engaged in hyperactivity of limbic regions and sensorimotor area. The insula, which is a part of the limbic system, includes various subregions with some distinct connectivity patterns separately. However, whether these insular subregions show different connectivity patterns respectively in PNES remains largely unknown. We aimed to investigate the functional connectivity (FC) of insular subregions in PNES and extend the understanding of the complex pathophysiological mechanisms of this disease. A resting-state FC based on the insular subregions were conducted in 18 patients and 20 healthy controls. We examined the differences in FC values between PNES patients and controls using two sample t test. Our results showed patients had significantly stronger FC between insular subregions and sensorimotor network, lingual gyrus, superior parietal gyrus and putamen, which suggested a hyperlink pattern of insular subregions involved in abnormal emotion regulation, cognitive processes and motor function in PNES. Pearson correlation analysis between the mean FC values within abnormal regions and the frequency of PNES further indicated PNES exhibited abnormal functional organization whose stressful emotion of patients have great direct influence on their motor functions. The differentially impaired functional connectivity patterns of insular subregions might provide new insights into the complex neurological mechanism of PNES.
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Affiliation(s)
- Rong Li
- Key Laboratory for Neuroinformation of Ministry of Education, School of Life Science and Technology, University of Electronic Science and Technology of China, Chengdu, 610041, People's Republic of China
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Güleç MY, Ýnanç L, Yanartaþ Ö, Üzer A, Güleç H. Predictors of suicide in patients with conversion disorder. Compr Psychiatry 2014; 55:457-62. [PMID: 24269192 DOI: 10.1016/j.comppsych.2013.10.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 10/15/2013] [Accepted: 10/17/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Previous studies have shown that the ratio of suicide attempts is between 19.6 and 34.2% in patients with conversion disorder (CD), yet few studies have addressed this issue. The present study compared demographic and clinical variables and predictors of suicide attempts in patients with CD. METHODS A total of 100 consecutive patients were recruited and divided into groups according to their history of suicide attempts. Socio-demographic variables such as economic status, age, gender, educational level, marital status, clinical variables such as the presence of psychiatric disorder in family, substance abuse, risky alcohol use, age of onset, subtype of CD, number of hospitalization were recorded. Participants also completed the Childhood Trauma Questionnaire (CTQ-28), Temperament and Character Inventory (TCI), Toronto Alexithymia Scale (TAS-20), Dissociative Experiences Scale (DES), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI). RESULTS Suicide attempters had a higher rate of risky alcohol use, more hospitalizations, and higher mean scores on the BAI, BDI, DES/DES-taxon, TAS-total and CTQ-total than did non-suicide attempters or healthy control (NHC). Patients with CD had a higher harm-avoidance and a lower self-directedness rather than NHC. Risky alcohol use, number of hospitalizations, and mean DES-taxon and emotional abuse scores were independent predictors of suicide attempts. CONCLUSION Our findings indicate that clinicians should be aware of the prediction of suicide in patients with CD who show dissociation and risky alcohol use. Moreover, a history of childhood emotional abuse should be considered in the management of CD. The fact that clinical variables distinguished between suicide attempters and non-attempters suggests that a history of suicide attempts may be used to clarify the heterogeneous nature of CD.
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Affiliation(s)
| | - Leman Ýnanç
- Erenköy Mental Research and Training Hospital, Istanbul, Turkey
| | - Ömer Yanartaþ
- Marmara University Pendik Research and Training Hospital, Psychiatry Department, Istanbul, Turkey
| | - Ahmet Üzer
- Erenköy Mental Research and Training Hospital, Istanbul, Turkey
| | - Hüseyin Güleç
- Erenköy Mental Research and Training Hospital, Istanbul, Turkey
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12
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Spiegel D, Lewis-Fernández R, Lanius R, Vermetten E, Simeon D, Friedman M. Dissociative Disorders in DSM-5. Annu Rev Clin Psychol 2013; 9:299-326. [DOI: 10.1146/annurev-clinpsy-050212-185531] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- David Spiegel
- Department of Psychiatry, School of Medicine, Stanford University, Stanford, California 94304-5718;
| | | | - Ruth Lanius
- Department of Psychiatry, London Health Sciences Center, London, N6A 5A5 ON Canada;
| | - Eric Vermetten
- Department of Psychiatry, University Medical Center Utrecht, 3584 CX Netherlands;
| | - Daphne Simeon
- Department of Psychiatry, Mt. Sinai School of Medicine, New York, New York 10025;
| | - Matthew Friedman
- Department of Psychiatry, Dartmouth Medical School, Hanover, New Hampshire 03755;
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13
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Hysterical paralysis after spinal surgery. Rheumatol Int 2011; 32:4077-8. [DOI: 10.1007/s00296-011-2257-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 10/22/2011] [Indexed: 10/15/2022]
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14
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Psychological distress, depression and generalised anxiety in Turkish and Moroccan immigrants in Belgium: a general population study. Soc Psychiatry Psychiatr Epidemiol 2009; 44:188-97. [PMID: 18726534 DOI: 10.1007/s00127-008-0431-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Accepted: 07/31/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND This study assesses the prevalence of and risk and protective factors for common mental health complaints in a general population sample of Turkish and Moroccan immigrants living in Belgium. Focus is on between- and within-group variation. METHODS The study is based on pooled data from the Belgian Health Interview Surveys 2001 and 2004 and focuses on the Turkish and Moroccan immigrant population aged 18-65 (N = 147 Turks, N = 359 Moroccans). Mental health status is assessed with the General Health Questionnaire-12 and the Symptom Checklist 90-R subscales for depression and generalised anxiety. Risk and protective factors considered are gender, age, household type, labor market position, educational level, household income, homeownership, being foreign- or native born and social support. RESULTS Between-group variance was not significant. Within-group analysis showed significant effects of gender and social support. Although not significant, the results suggested positive associations between social adversity and mood status. In addition, there was a tendency for higher risks for psychological distress, depression and generalised anxiety in foreign-born as compared to Belgian-born Turkish and Moroccan immigrants.
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Espirito-Santo H, Pio-Abreu JL. Psychiatric symptoms and dissociation in conversion, somatization and dissociative disorders. Aust N Z J Psychiatry 2009; 43:270-6. [PMID: 19221916 DOI: 10.1080/00048670802653307] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Conversion, dissociation and somatization are historically related in the long established concept of hysteria. Somewhere along the way they were separated due to the Cartesian dualistic view. The aim of the present study was to compare these pathologies and investigate whether symptoms of these pathologies overlap in their clinical appearance in a Portuguese sample. METHOD Twenty-six patients with conversion disorder, 38 with dissociative disorders, 40 with somatization disorder, and a comparison group of 46 patients having other psychiatric disorders answered questions about dissociation (Dissociative Experiences Scale), somatoform dissociation (Somatoform Dissociation Questionnaire), and psychopathological symptoms (Brief Symptom Inventory). RESULTS Dissociative and somatoform symptoms were significantly more frequent in dissociative and conversion disorder than in somatization disorder and controls. There were no significant differences between dissociative and conversion patients. CONCLUSIONS Conversion disorder is closely related to dissociative disorders. These results support the ICD-10 categorization of conversion disorder among dissociative disorders and the hypothesis of analogous psychopathological processes in conversion and dissociative disorders versus somatization disorder.
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Affiliation(s)
- Helena Espirito-Santo
- Departmento de Psicologia, Instituto Superior Miguel Torga, Coimbra, Largo da Cruz de Celas, Coimbra, Portugal.
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16
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Sar V, Akyüz G, Dogan O, Öztü E. The Prevalence of Conversion Symptoms in Women From a General Turkish Population. PSYCHOSOMATICS 2009; 50:50-8. [DOI: 10.1176/appi.psy.50.1.50] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Abstract
PURPOSE Patients with conversion disorder present with symptoms of sensory and motor dysfunction that are not explained by known physical disorders or pathophysiological mechanisms. Correct diagnosis and prompt, effective management of patients with this disorder is essential. Healthcare providers may be unaware of the important role of physical therapy in the management of patients with conversion disorder. While numerous reports have suggested the need for physical therapy management of this disorder, there is a lack of reports outlining specific physical therapy management principles or daily treatment progression. The purpose of this series of case reports is to provide an overview of conversion disorder and describe successful physical therapy management strategies used to treat three patients with movement impairment due to this disorder. CASE DESCRIPTION The patients were 18-, 20-, and 34-year-old women treated in a hospital inpatient rehabilitation setting. Behavioral modification and shaping techniques formed the basis for the physical therapy treatment approach. Abnormal movement patterns were ignored, and correct movement patterns were reinforced using feedback and praise. The patients advanced through a progressively more difficult therapy program based on treatment approaches used with analogous neurological conditions. OUTCOMES All three patients showed complete resolution of their symptoms and returned to independent mobility, independent living, and to work or school.
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Affiliation(s)
- Debra Ness
- Mayo Clinic, Rochester, Minnesota, MN, USA.
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18
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Ozenli Y, Ozisik HI, Tugal O, Yoldascan E. Health-related quality of life in patients with conversion disorder with seizures. Int J Psychiatry Clin Pract 2008; 12:105-11. [PMID: 24916620 DOI: 10.1080/13651500701679379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective. The concept of Health-Related Quality of Life (HRQOL) is important for both the prevention and progress of psychiatric diseases. In the literature, we are aware that there are a few studies on HRQOL among patients with conversion disorder with seizure. Our aim is to measure the HRQOL in Turkey among patients with conversion disorder with seizure and to compare the quality of life of this study group to a healthy control group and to different types of epileptic patient groups. Methods. A total of 330 subjects was included in this study; 102 patients were included in the conversion disorder group, 121 patients were included in the epileptic group and 93 subjects were included in the healthy control group. WHOQOL-100 scale and Trait Anxiety Inventory (TAI) were administered to these groups. Results. HRQOL for the patients with conversion disorder was worse than the control group except for the environment and social relations domains. The generalized epilepsy patients had better physical and psychological health, compared with the patients with conversion disorder. Compared with the partial epilepsy group, HRQOL for the patients with conversion disorder was better in psychological, environmental, social relationship domains. Conclusion. Considering these disorders, patients with conversion disorder need long-term psychiatric treatment. Carrying out this study in our country will be an advantage for the cross-cultural studies which will be undertaken out in the future.
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Affiliation(s)
- Yarkin Ozenli
- Department of Psychiatry, Baskent University Faculty of Medicine, Baskent, Turkey
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Deveci A, Taskin O, Dinc G, Yilmaz H, Demet MM, Erbay-Dundar P, Kaya E, Ozmen E. Prevalence of pseudoneurologic conversion disorder in an urban community in Manisa, Turkey. Soc Psychiatry Psychiatr Epidemiol 2007; 42:857-64. [PMID: 17639308 DOI: 10.1007/s00127-007-0233-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Accepted: 06/25/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is not a wide agreement upon rate of conversion disorder within Turkish population. The aim of this study was to determine the prevalence of conversion disorder with pseudoneurological symptoms or deficits and related risk factors in a city. METHOD In total, 1,086 people, aged 15-65 years old, were selected from the city of Manisa, Turkey to take part in the study. We applied sociodemographic and health information questionnaires and the Composite International Diagnostic Interview (CIDI) Somatization Subscales to the samples. RESULTS The likelihood that an individual might have conversion disorder with pseudoneurological symptoms or deficits was found to be 5.6% (n = 61). The prevalence of conversion disorder with pseudoneurological symptoms or deficits was significantly higher among women (p < 0.0001), 15-24 year old women (p = 0.011) and 25-34 year old women (p = 0.003), people who live as squatters (p = 0.03), those with a history of psychiatric disorder (p < 0.0001) and those having a mother with a psychiatric disorder (p = 0.04). CONCLUSION This study has shown the conversion disorder with pseudoneurological symptoms or deficits is inadequately frequent in the population.
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Affiliation(s)
- Artuner Deveci
- Dept. of Psychiatry, Celal Bayar University Medical School, 45030, Manisa, Turkey.
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20
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Levecque K, Lodewyckx I, Vranken J. Depression and generalised anxiety in the general population in Belgium: a comparison between native and immigrant groups. J Affect Disord 2007; 97:229-39. [PMID: 16901547 DOI: 10.1016/j.jad.2006.06.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Revised: 06/26/2006] [Accepted: 06/26/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Knowledge of the mental health status of the general population in Belgium is limited. Only recently have prevalence rates and risk factors for depression and generalised anxiety been identified. However, the question remains whether there are statistically significant differences between foreign origin groups and the native population. METHODS Basing our study on data from the Belgian Health Interview Survey 2001 and focusing on the adult population aged 18-65 (N=7224), we consider eight risk factors for depression and generalised anxiety as assessed by the Symptom Checklist 90-subscales. The risk factors are region of origin, gender, age, household type, labour market position, educational level, household income and home ownership. Our approach involves weighted logistic regression. RESULTS Analysis shows that most depressive symptoms are more prevalent among persons of Turkish or Moroccan origin than among Belgians or people from other EU Member States. This is not the case, though, for anxiety symptoms. However, if we consider depression and generalised anxiety as a syndrome, we find significantly more of the 10% highest SCL-scores in Turkish and Moroccan immigrants. Multivariate analysis indicates that their higher prevalence rate of anxiety is entirely attributable to their lower socioeconomic position. In the case of depression, the risk decreases only partly, leaving a significant association with Turkish or Moroccan origin. CONCLUSION In Belgium, depression and generalised anxiety are more prevalent in the population originating from Turkey and Morocco than in population groups originating from within the European Union.
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Affiliation(s)
- Katia Levecque
- University of Antwerp, Faculty of Political and Social Sciences-Research Unit on Poverty, Social Exclusion and the City (OASeS), Belgium.
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Affiliation(s)
- Elizabeth S Bowman
- Indiana University Epilepsy Clinic, University Hospital, 550 N. University Boulevard, Ste. 1711, Indianapolis, IN 46202, USA.
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Strassnig M, Stowell KR, First MB, Pincus HA. General medical and psychiatric perspectives on somatoform disorders: separated by an uncommon language. Curr Opin Psychiatry 2006; 19:194-200. [PMID: 16612203 DOI: 10.1097/01.yco.0000214348.38787.d3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW While Diagnostic and Statistical Manual of Mental Disorders-IV provided updated definitions and diagnostic criteria for the diagnoses subsumed under the category of somatoform disorders, various nosological questions are still unresolved. We assessed current research activity on important key concepts related to nosology, validity, and reliability of the Diagnostic and Statistical Manual of Mental Disorders-IV somatoform diagnoses. RECENT FINDINGS The initial Medline search for articles from 2000 through 2005 yielded a total of 912 articles. After checking for redundancy and excluding publications using other than Diagnostic and Statistical Manual of Mental Disorders-IV diagnostic criteria, a total of 101 articles was further reviewed. Heterogeneity of papers precluded statistical approaches; thus, a descriptive and narrative review was pursued. SUMMARY It appears that applying the specific categories and criteria as proposed by Diagnostic and Statistical Manual of Mental Disorders-IV only captures a small proportion of the phenomena of interest at the interface of medicine and psychiatry. A paradigm shift towards 'general medical/psychiatry interface disorders' in exchange for the current dichotomy of 'mind' vs. 'body' disorders, may reduce stigma associated with current diagnostic labeling, improve user acceptability, and stimulate research in this important but still fragmented clinical area that still lacks agreed-upon diagnostic definitions.
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Affiliation(s)
- Martin Strassnig
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
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Rufer M, Held D, Cremer J, Fricke S, Moritz S, Peter H, Hand I. Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. PSYCHOTHERAPY AND PSYCHOSOMATICS 2006; 75:40-6. [PMID: 16361873 DOI: 10.1159/000089225] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD. METHODS Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy. RESULTS Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs. CONCLUSIONS Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.
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Affiliation(s)
- Michael Rufer
- Department of Psychiatry and Psychotherapy, Centre of Psychosocial Medicine, University Hospital of Hamburg, Germany.
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Ikeda K, Osamura N, Hashimoto N, Funaki K, Tomita K. Conversion disorder: four case reports concerning motor disorder symptoms. J Orthop Sci 2005; 10:324-7. [PMID: 15928898 DOI: 10.1007/s00776-005-0888-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 01/13/2005] [Indexed: 02/09/2023]
Affiliation(s)
- Kazuo Ikeda
- Department of Orthopaedic Surgery, School of Medicine, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
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