Associated features of conversion disorder in Turkish adolescents

Characteristics of Conversion Disorder in an Urban Academic Children's Medical Center

Background. Literature on childhood conversion disorder (CD) is sparse and is mostly limited to the outpatient population. Method. Our study retrospectively examines the characteristics of childhood CD in 42 children and adolescents seen by the psychiatric consultation-liaison service in an urban academic medical center with a large minority population. Results. CD accounted for 11% of our consultations. The majority of patients were female adolescents, but in the younger cohort, the male-to-female ratio equalized. Other somatic symptoms and additional psychiatric diagnoses were common, anxiety disorders in particular. Antecedent stressors were identified in 95% of patients, most commonly related to family stressors. Recent or remote history of abuse was rare. Neurological presentations were complex, with almost half of the patients presenting with multiple distinct neurological symptoms. Hyperkinetic symptoms were more common than hypokinetic symptoms, and paroxysmal symptoms were more common than non-paroxysmal. No distress (la belle indifference) was found in only 25% of patients and about half of patients had no socio-academic impairment. High resource utilization was noted based on multiple specialist consultants, diagnostic studies, and length of stay. Conclusion. Much of our data confirms previous findings and contributes to what is becoming a more robust characterization of this population.

Dissociative sensibility disorders - A retrospective case series and systematic literature review

CONTEXT

Dissociative disorders present a huge challenge in clinical settings. In contrast to other dissociative symptoms, dissociative sensibility disorders are rarely focused on.

OBJECTIVE

To identify the clinical characteristics and outcomes of dissociative sensibility disorders in children and adolescents, and to review the use of diagnostic procedures.

DATA SOURCES

For the review, a literature search used Pubmed, Embase, Web of Science, and PubPsych (to 02/2015) and the reference lists of the studies identified.

STUDY SELECTION

Screening of titles and abstracts; full-text assessment by two reviewers.

DATA SELECTION

The original case series was identified by using the local data register.

DATA EXTRACTION

Two reviewers independently reviewed the data and, if they agreed on the relevance, extracted the data. In the original case series, data were extracted retrospectively from the records.

RESULTS

Sixteen studies and seven case reports were identified, including 931 cases with dissociative disorders. In 210 cases the patient suffered either from a single sensibility disorder or predominantly from sensibility disorders. We identified thirteen further cases in our cohort. In both groups there was female predominance; the mean age of manifestation was early adolescence. The timing of admissions was variable. In approximately 50% of cases a premorbid stressful life event could be identified. Over 75% of cases had a good prognosis with complete resolution.

LIMITATIONS

Retrospective character of our own data collection, partially missing differentiation between the subgroups of dissociative disorders in the reviewed studies.

CONCLUSIONS

There is no uniform procedure for diagnostic work-up. The overall short-term prognosis is good.

Health-related quality of life in adolescents with psychogenic nonepileptic seizures

The aim of this study was to evaluate the health-related quality of life (HRQoL) in adolescents with psychogenic nonepileptic seizures (PNESs) and to identify factors affecting the quality of life in these patients. Thirty-four adolescents with PNESs were compared to 30 adolescents without any psychiatric disorder. The Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL) was applied to determine comorbid psychiatric disorders in the study group and to rule out any psychiatric disorder in the control group. The Pediatric Quality-of-Life Inventory (PedsQL) was used to assess the HRQoL. Physical HRQoL and psychosocial HRQoL, including emotional and school functioning, were found to be significantly lower in adolescents with PNESs. In the group with PNESs, the physical HRQoL and total HRQoL of adolescents with somatoform disorders other than PNESs and the emotional functioning of adolescents with major depressive disorder were worse than those of the adolescents without these comorbid psychiatric disorders. Seizure frequency and the duration of symptoms were not correlated with HRQoL scores. Treatment strategies in adolescents with PNESs should regard comorbid unexplained somatic symptoms and psychiatric disorders in addition to the reduction or cessation of seizures.

Headaches as somatoform disorders in children and adolescents

Somatoform disorders are often the main cause for seeking professional advice and performing a number of specialist checks. The aim of the study was to determine the frequency of somatoform disorders in the form of headaches in children and adolescents neurologically diagnosed and the risk factors thereof. Analysis of the biological and situational risk factors were established. Somatoform disorders were diagnosed in 27 out of 276 children with headaches. We concluded that in the differential diagnosis of headaches, somatoform headaches should not be omitted as every 10(th) patient in the developmental age diagnosed on the neurological ward because of headache shows signs of somatoform headaches. In diagnostically difficult cases it is recommended that analysis of biological and situational risk factors be performed with special attention paid to chronic disease of the patient and/or in his immediate family, the patient's psychological disorders and dysfunctional or low social status families. The creation of separate criteria for somatoform disorders of the developmental age should be considered.

Konversionsstörungen: Störungsbild, Diagnostik, Psychoedukation und Intervention

Konversionsstörungen umfassen nichtepileptische Anfälle sowie sensorische oder motorische Funktionsausfälle (Gangstörungen, Kraftverlust und Lähmung, Sprechstörungen) ohne organmedizinische Ursache. Sie nehmen in klassifikatorischer, ätiologischer und therapeutischer Hinsicht eine Zwischenstellung zwischen den somatoformen und dissoziativen Störungen ein. Bei hohen Raten psychopathologischer Vulnerabilität und Komorbidität können traumatische Erfahrungen, akute Belastungsfaktoren sowie aktuell überfordernde Entwicklungsaufgaben als Auslöser wirken. Besonders typisch ist ein emotional invalidierendes Familienklima, das den authentischen und direkten Ausdruck von Bedürfnissen und Befindlichkeiten des Kindes hemmt. Die Manifestation der Konversionssymptome erfüllt einerseits eine entlastende und verstärkende Funktion, erzeugt andererseits aber neue Belastungsfaktoren wie funktionelle Behinderung, Einschränkungen der sozialen und schulischen Teilhabe, hypochondrische Sorge vor einer unerkannten Grunderkrankung sowie Angst vor Stigmatisierung als Simulant oder psychisch Kranker. Ein Störungsmodell wird vorgestellt, das auch als Grundlage für einen Leitfaden zur klinisch-psychologischen Exploration, Anamneseerhebung, Fallkonzeption sowie das das Procedere der Diagnosemitteilung dient. Patientenorientierte Metaphern werden im Rahmen der Psychoedukation eingesetzt, um die Entstehung der Symptomatik trotz intakter neuronaler Reizleitung für Patient und Eltern nachvollziehbar zu gestalten. Die psychotherapeutische Intervention startet mit einer schrittweisen Wiederaufnahme altersgerechter Aktivitäten und Rollen. Physiotherapie zum Training der geschwächten Muskulatur wird initiiert, um dem Patienten ein Ritual anzubieten, das eine Wiederherstellung der Funktionsausfälle ohne Gesichtsverlust ermöglicht. Psychotherapeutische Strategien im engeren Sinne greifen die vorgegebene Dissoziation des Bewusstseins von der körperlichen Symptomatik auf. Altersgerecht wird dem Kind ein Persönlichkeitsanteil beschrieben, der die Symptomatik überwinden will, ein anderer Persönlichkeitsanteil wird gegenübergestellt, der die Konversionssymptomatik und dessen Anliegen repräsentiert. Der Therapeut entwickelt und moderiert mit dem Kind Lösungen, die geeignet sind, beide Persönlichkeitsanteile wieder neu zu integrieren und damit die Dissoziation zwischen Bewusstsein und körperlicher Symptomatik aufzulösen.

Sex distribution and psychiatric features of child and adolescent conversion disorder across 2 decades

BACKGROUND

Earlier research suggested female predominance in adult conversion disorder, and the strong association between conversion disorder and experiences of being abused is well known. However, the data for child and adolescent populations are limited. In Taiwan, the dramatic increase in child abuse may have some impact on the features of child and adolescent conversion disorder. This study aimed to compare the demographic characteristics, psychiatric comorbidity, and experiences of being abused in Taiwanese children and adolescents diagnosed with conversion disorder in psychiatric consultations across 2 decades.

METHODS

Retrospective and consecutive chart reviews were conducted for child and adolescent patients (< 20 years old) who were newly diagnosed with conversion disorder in psychiatric consultations at Taipei Veterans General Hospital from 1987 to 2006. The first group included patients who were diagnosed between 1987 and 1996 (the first decade), and the second group included patients who were diagnosed between 1997 and 2006 (the second decade).

RESULTS

A total of 42 patients diagnosed with conversion disorder were included in this study. Nineteen of the 42 subjects were diagnosed in the first decade (from 1987 to 1996), and 23 in the second decade (from 1997 to 2006). There existed among patients a tendency toward an increasing number of male subjects (p < 0.05), suffering more abuse (p < 0.05), and higher prevalence rates of depression and dysthymia comorbidity (p < 0.05) in the second decade compared to the first.

CONCLUSION

The sex distribution in conversion disorder might have significantly changed over the past 2 decades. There is an increasing need for screening and interventions for psychiatric comorbidity and experiences of being abused in children and adolescents with conversion disorder. Because of the small sample size of our study, further studies that include multiple study sites and a larger number of patients are needed before a firm conclusion can be drawn.

Psychogenic movement disorders in children

Psychogenic movement disorders (PMDs) are well characterized in adults, but childhood-onset PMDs have not been extensively studied. We reviewed the medical records of children who were diagnosed in our clinic with PMDs since 1988 and identified 54 patients with PMDs, representing 3.1% of our pediatric movement disorder population and 5.7% of all PMD cases. The mean age at symptom onset was 14.2 years (+/-2.11, range 7.6-17.7). Similar to published data in adults, two-thirds of children exhibited multiple PMD phenotypes, the most common being tremor followed by dystonia and myoclonus. Most PMDs were abrupt in onset, paroxysmal and triggered by identifiable physical or psychological trauma. As in adults, childhood PMDs were more likely to affect females, but there was no female predominance in children less than 13 years old. Although prior studies suggest that medically unexplained symptoms beginning in childhood often follow a benign course, this cohort of children experienced marked disability and morbidity related to PMDs, including prolonged school absences and unnecessary surgical procedures in more than one-fifth of patients.

Prevalence of pseudoneurologic conversion disorder in an urban community in Manisa, Turkey

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.

Pediatric stress-related seizures: conceptualization, evaluation, and treatment of nonepileptic seizures in children and adolescents

PURPOSE OF REVIEW

Nonepileptic seizures are seizure-like symptoms that occur in the absence of epileptogenic brain activity. They can cause severe compromise of daily function and impede development in children, and are frequently misdiagnosed, leading to inadequate or potentially harmful medical treatment. This review will characterize nonepileptic seizures, identify associated factors, propose to a reconceptualization of the phenomenon as stress-related seizures, and suggest guidelines for valid diagnosis and intervention.

RECENT FINDINGS

Nonepileptic seizures occur in 10 to 20% of children who present to epilepsy centers, and are more common in females. Early intervention improves prognosis. Factors associated are physical, sexual and other trauma, family dysfunction, and other acute or chronic stressors. They are frequently misdiagnosed and inappropriately treated. Therapy redirecting preoccupation with worries has been effective.

SUMMARY

Nonepileptic seizures are best conceptualized and referred to as stress-related seizures. Long Term Video-EEG Monitoring (LTM) is the gold standard for diagnosis. Diagnosis and intervention requires collaboration between primary care physicians, neurologists, and medically oriented clinicians providing individual and family psychotherapeutic intervention.

Psychogenic status epilepticus in children

Epilepsy features, psychiatric profile, psychosocial factors, and outcome are described for six children (three males) aged 5-15 years (mean 12.1) with psychogenic status epilepticus (PSE), i.e., prolonged or repetitive psychogenic seizures (PSs), >30 minutes, simulating status epilepticus. They had epilepsy, they were on chronic anticonvulsants (ACVs), and some had other neurological deficits. All received intravenous and/or rectal ACVs prior to suspicion of PSE. PSE was confirmed via video/EEG, demonstrating no epileptogenic activity during alleged seizures. Provocation and placebo therapy techniques were used in two. Psychiatric assessment identified comorbid disorders such as depression, anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, and posttraumatic stress disorder. Psychosocial stressors were almost ubiquitous. Psychiatric intervention included psychotherapy, family therapy, and medical treatment in one patient. Outcome was monitored for an average of 3.6 years (3-5 years). PSE did not recur. PSs recurred in three. Psychiatric comorbidity improved in four, who accepted psychiatric intervention and whose epilepsy also improved. In conclusion, the occurrence of PSE in children and adolescents with epilepsy is stressed. Prompt diagnosis was often missed in the acute care setting, and this carries important implications for iatrogenic complications. PSE diagnosis resulted in identification and management of comorbid psychiatric disorders. This was probably important in reducing the predominating anxiety and affective disorders in most patients as well as PSE recurrence. Epilepsy severity and associated deficits were most likely important factors in determining outcome.