Trauma-related dissociative (conversion) disorders in children and adolescents--an overview of assessment tools and treatment principles

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder

LEARNING OBJECTIVES

• Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions.

ABSTRACT

Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.

Characteristics and outcomes of children with dissociative (conversion) disorders in western China: a retrospective study

BACKGROUND

Dissociative (conversion) disorder in children is a complex biopsychosocial disorder with high rates of medical and psychiatric comorbidities. We sought to identify the characteristics and outcomes of children with dissociative (conversion) disorders in western China.

METHODS

We conducted a retrospective cohort study of 66 children admitted with dissociative (conversion) disorders from January 2017 to July 2019, and analyzed their clinical characteristics, socio-cultural environmental variables, and personality and psychiatric/psychological characteristics. Binary logistic regression was used to analyze the variables associated with clinical efficacy.

RESULTS

Of these 66 patients, 38 (57.6%) were male and 28 (42.4%) were female, 46 (69.7%) had an antecedent stressor, 30 (45.5%) were left-behind adolescents, and 16 (24.2%) were from single-parent families. In addition, 30 patients (45.5%) were not close to their parents, 38 patients (59.4%) had an introverted personality, and 34 (53.1%) had unstable emotions. Thirteen families (19.7%) were uncooperative with the treatment. Patients who had cormorbid anxiety or depression exhibited significantly lower cognitive ability (P < 0.01). Logistic regression found that better treatment outcomes were positively associated with having a close relationship with parents, parental cooperation with treatment, and having a father with a lower level of education (i.e., less than junior college or higher).

CONCLUSIONS

The characteristics and outcomes of children with dissociative (conversion) disorders are related to socio-cultural environmental variables and psychiatric/psychological factors. Timely recognition and effective treatment of dissociative (conversion) disorders are important.

Psychosocial interventions for conversion and dissociative disorders in adults

BACKGROUND

Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them.

OBJECTIVES

To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults.

SEARCH METHODS

We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies.  SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial).  DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias.

MAIN RESULTS

We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1).  The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17  studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect.

AUTHORS' CONCLUSIONS

The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.

Emotion regulation strategies in trauma-related disorders: pathways linking neurobiology and clinical manifestations

Emotion regulation impairments with traumatic origins have mainly been studied from posttraumatic stress disorder (PTSD) models by studying cases of adult onset and single-incident trauma exposure. The effects of adverse traumatic experiences, however, go beyond the PTSD. Different authors have proposed that PTSD, borderline personality, dissociative, conversive and somatoform disorders constitute a full spectrum of trauma-related conditions. Therefore, a comprehensive review of the neurobiological findings covering this posttraumatic spectrum is needed in order to develop an all-encompassing model for trauma-related disorders with emotion regulation at its center. The present review has sought to link neurobiology findings concerning cortico-limbic function to the field of emotion regulation. In so doing, trauma-related disorders have been placed in a continuum between under- and over-regulation of affect strategies. Under-regulation of affect was predominant in borderline personality disorder, PTSD with re-experiencing symptoms and positive psychoform and somatoform dissociative symptoms. Over-regulation of affect was more prevalent in somatoform disorders and pathologies characterized by negative psychoform and somatoform symptoms. Throughout this continuum, different combinations between under- and over-regulation of affect strategies were also found.

Dissoziative Amnesie und Migration

Zusammenfassung. Dissoziative Amnesie verläuft unter Umständen chronisch und kann zu lebenslanger Arbeitsunfähigkeit führen. Die Krankheit tritt gehäuft im Zusammenhang mit Migration auf und verläuft dann schwerer als in anderen Fällen. Sie ist im Grunde reversibel, d. h., der Abruf der Gedächtnisinhalte ist nur blockiert. Betroffen sind Patienten, die nicht verarbeitete Stress- und Traumaerlebnisse als Hintergrund haben und dann ein erneutes Stresserlebnis erfahren, welches zum dissoziativen Amnesiezustand führt. Es wird postuliert, dass in erster Linie Patienten betroffen sind, die im neuen Heimatland nicht ausreichend und ihrem Anspruch entsprechend Fuß fassen konnten. Mangelnde Sprachkenntnisse und eine nicht den Erwartungen entsprechende neue Arbeitssituation sind am ehesten als Gründe anzuführen.

Validity and reliability of the Turkish version of the DSM-5 Dissociative Symptoms Severity Scale-Child Form

The goal of this study was to assess the validity and reliability of the Turkish version of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) Dissociative Symptoms Severity Scale-Child Form. The scale was prepared by translating and then back-translating the DSM-5 Dissociative Symptoms Severity Scale. The study groups included one group of 30 patients diagnosed with posttraumatic stress disorder who were treated in a child and adolescent psychiatry unit and another group of 83 healthy volunteers from middle and high schools in the community. For assessment, the Adolescent Dissociative Experiences Scale (ADES) was used in addition to the DSM-5 Dissociative Symptoms Severity Scale. Regarding the reliability of the DSM-5 Dissociative Symptoms Severity Scale, Cronbach's alpha was .824 and item-total score correlation coefficients were between .464 and .648. The test-retest correlation coefficient was calculated to be r = .784. In terms of construct validity, one factor accounted for 45.2% of the variance. Furthermore, in terms of concurrent validity, the scale showed a high correlation with the ADES. In conclusion, the Turkish version of the DSM-5 Dissociative Symptoms Severity Scale-Child Form is a valid and reliable tool for both clinical practice and research.

[Conversion Disorder in Children and Adolescents]

BACKGROUND

Conversion disorder is diagnosed late, by exclusion and with a high risk of complications. There is a wide experience in adults that is not extrapolated to paediatric patients. According to the literature, the prognosis is better in children, but this changes when other variables such are included, such as comorbidities, late diagnosis and a very convincing social image of the neurological disease.

OBJECTIVE

To review the medical literature on the clinical features, diagnosis, comorbidities and treatment of this disorder.

METHODS

A literature research was performed on Medline and Pubmed, the terms used were "conversion disorder", pseudoseizures, treatment, clinic, children ("conversion disorder" OR hysteria OR hysterical) (child OR children OR childhood OR pediatric OR paediatric). The most relevant material found is included in this review.

CONCLUSIONS

Conversion disorder is often an imprecise diagnosis in high complexity paediatric services. No consensus was found in the literature search on how to treat patients after the initial diagnosis. The evidence that it becomes chronic is not strong enough, just as the evidence is not convincing enough to argue that comorbidity factors are those maintained over time. Clearly, there is no medical experience of the natural history of this disorder in children and adolescents. It is only known is that it is a complex condition, on which there is experience only in the diagnosis and treatment of the acute state, but not so in the long-term care. It is proposed that each patient is studied in detail in order to define the psychiatric diagnosis and its treatment.

Screening for post-traumatic stress disorder after injury in the pediatric emergency department--a systematic review protocol

BACKGROUND

Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.

METHODS

Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data (specificity, positive and negative likelihood/odds ratios) where appropriate.

DISCUSSION

Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.

TRIALS REGISTRATION

PROSPERO registration: CRD42013004893.

The Experiences of Educational Psychologists Who Utilise Ego-State Therapy to Address Dissociation in Adolescents

Ego-state therapy is regarded an effective therapeutic technique for addressing dissociation. However, studies by psychologists (especially educational psychologists) who utilise ego-state therapy with adolescents presenting with dissociation are not readily available. This article derives from such a study aimed at exploring the experiences of educational psychologists with regard to the process followed in ego-state therapy, as well as its appropriateness for adolescents experiencing dissociation. Data were collected from four participants through incomplete sentences, semi-structured interviews, and symbolic artefacts, using a phenomenological research design. The findings demonstrate the value of utilising ego-state therapy as a therapeutic intervention for adolescents manifesting with dissociation.

Dissoziation und Konversion

Terminologie und Konzepte der Dissoziation und Konversion sind seit über einem Jahrhundert in der tiefenpsychologischen Tradition verankert, während die empirisch ausgerichtete Klinische Psychologie und Kinderpsychologie deren Erforschung weitgehend vernachlässigt hat. Aus psychologischer Perspektive zeigen gerade Kinder spontan viele dissoziative Erlebens- und Verhaltensweisen (z. B. Tagträumen). Diese weisen eine wichtige Funktion bei der Emotions- bzw. Affektregulation von alltäglichen Stressoren bis hin zu Extrembelastungen und traumatischen Erfahrungen auf (z. B. Verkehrsunfall, körperliche Misshandlung, sexualisierte Gewalt). Sie schützen zumindest kurzfristig das Bewusstsein vor sensorischer, kognitiver und affektiver Überlastung. Aus kategorialer Perspektive liegt eine Störungswertigkeit bei dissoziativen Störungen vom Bewusstseinstypus in Form von spezifischen Amnesien, Konfusion, Stupor und Identitätsstörungen sowie in Form von Konversionsstörungen (motorische und sensorische Ausfälle, nichtepileptische Anfälle) ohne organmedizinische Grundlage vor. Dissoziative Störungsbilder weisen enge Bezüge zu den somatoformen Störungen, zur akuten Belastungsreaktion und zur posttraumatischen Belastungsstörung sowie zu emotional instabilen und histrionischen Persönlichkeitsstörungen auf. Bis heute fehlt den vorliegenden therapeutischen Ansätzen weitgehend eine evidenzbasierte Fundierung. In der Zukunft verdienen dissoziative Störungsbilder und Bewältigungsmechanismen nicht nur eine besondere Aufmerksamkeit der Forschung aus psychopathologischer Sicht, sondern auch aus therapeutischer Sicht. Die sogenannte dritte Welle der Verhaltenstherapie mit ihren unterschiedlichen Strömungen achtsamkeitsbasierter Therapie (Acceptance and Commitment Therapy, Metakognitive Therapie, Dialektisch-behaviorale Therapie, Schematherapie) beginnt das psychotherapeutische Potenzial zu entdecken, das in einer gezielten, therapeutisch induzierten Dissoziation liegen kann. Dissoziative Techniken, mit deren Hilfe der Patient aus sicherer Distanz bedrohliche oder traumatische Bewusstseinsinhalte betrachten kann, stellen eine effektive Methode dar, wahrnehmungsbezogenes Vermeidungsverhalten zu überwinden.

Dissoziative Störungen mit Beginn im Kindes- und Jugendalter

Zu den dissoziativen Störungen vom Bewusstseinstyp werden psychogene Syndrome mit Amnesie, Stupor, Fugue, Trance- und Besessenheit, Identitätsdiffusion sowie Depersonalisation und Derealisation gerechnet. Dissoziative Symptome treten nicht nur im Rahmen dieser dissoziativen Störungen auf, sondern auch bei anderen, vor allem posttraumatischen Störungen. Dass behandlungsbedürftige dissoziative Syndrome bereits im Kindesalter vorkommen, ist unbestritten. Allerdings fehlen adaptierte diagnostische Kriterien für diese Altersgruppe. Stark ergänzungsbedürftig sind auch die Erkenntnisse zu Auftretenshäufigkeit, Komorbidität und Verlauf des Störungsbildes. Behandlungsstrategien sind nicht hinreichend evidenzbasiert. Vor diesem Hintergrund wird ein kurzer Überblick zu Symptomatik, Diagnostik, Komorbidität, Verlauf und Behandlung psychoformer dissoziativer Störungen im Kindes- und Jugendalter gegeben.

Childhood trauma and dissociation in women with pseudoseizure-type conversion disorder

BACKGROUND

Conversion disorder is thought to be associated with psychological factors because of the presence of conflict and other stressors prior to the condition.

AIM

The aim of this study is to compare adult patients with pseudoseizure-type conversion disorder with healthy control group in terms of childhood trauma, dissociative disorder and family history of psychiatric disorders.

METHOD

56 female patients were admitted to the general psychiatry hospital outpatient clinic between January and July 2005. All patients had a negative experience about their families just before having the conversion. Diagnosis was made according to the DSM-IV criteria. A control group consisting of similar patient demographics of the disease group has been selected. Socio-demographic information forms, the Childhood Trauma Questionnaire (CTQ) and Dissociation Questionnaire (DIS-Q), were completed on the patients.

RESULTS

CTQ total (t=12.12, P<0.001) and subscales, emotional abuse and emotional neglect (EA-EN) (t=12.74, P<0.001), physical abuse (PA) (t=10.05, P<0.001), and sexual abuse (SA) (t=7.69, P<0.001) were significantly high in the conversion group. DIS-Q mean points were statistically higher in the conversion group (t=11.05, P<0.001).

CONCLUSIONS

The findings suggest that pseudoseizures (conversion disorder) should be included within dissociative disorders in DSM system as in ICD. It is usually uncommon for the patient to tell about childhood trauma without being specially questioned about this issue. Thus, it would be helpful to uncover these experiences by using related scales in conversion disorder patients.

The Korean Version of the Adolescent Dissociative Experience Scale: Psychometric Properties and the Connection to Trauma among Korean Adolescents

OBJECTIVE

The Adolescent Dissociative Experience Scale (A-DES) is a screening measure for dissociative experience in adolescents. The present study aimed to investigate the reliability, validity and psychometric properties of the Korean version of the Adolescent Dissociative Experience Scale.

METHODS

The Korean version of the A-DES was administered to a normative group of 371 adolescents aged 12 to 18 years and a traumatized group of 33 adolescents aged 12 to 18 years with known trauma.

RESULTS

The internal consistency was excellent (Cronbach's alpha=0.91) and the test-retest correlation of the A-DES was high (r=0.99). Correlation between the A-DES and other measures of dissociation was moderate (r=0.48). There were no significant age differences in mean total A-DES scores for the normative sample, or for boys or girls separately. Nor were there any significant gender differences for any age group. The mean total score of the A-DES was significantly higher in the traumatized group than in the normative group. There was a statistically significant difference between adolescents with self-reported trauma and those without a trauma history in the normative group.

CONCLUSION

This study demonstrated that the Korean version of the A-DES is a reliable measure with excellent internal consistency and good stability over a 4-week test-retest interval with single factor structure. It can be used to screen for dissociative symptoms in Korean adolescents between the ages 12 and 18.

Hypnotherapy in child psychiatry: the state of the art

Children are more easily hypnotized than adults, and hypnotherapy as a method responds to the general developmental needs of children by addressing their ability for fantasy and imagination. Hypnotherapy and self-hypnosis are tools with which to assess and develop protective factors, and enhance positive adjustment. Meta-analyses and overviews have demonstrated the effect of hypnotherapy in paediatric disorders like asthma, chronic and acute pain, and in procedure-related distress in cancer patients. We wanted to examine the use and benefits of hypnotherapy when applied to child psychiatric disorders. A review of a literature search from PubMed, PsychINFO and the Cochrane databases revealed 60 publications, mostly case reports based on 2-60 cases, addressing the use of hypnotherapy in various child psychiatric conditions. Findings indicate that hypnotherapy may be useful for a wide range of disorders and problems, and may be particularly valuable in the treatment of anxiety disorders and trauma-related conditions. In conclusion, knowledge of hypnosis is useful in clinical practice and hypnotherapy may play an important role as an adjunctive therapy in cognitive-behavioural treatment and family therapy. Additional qualitative and quantitative studies are needed to assess the place for hypnosis/hypnotherapy in child psychiatry.