The behavioral treatment of hysterical paralysis in a ten-year-old boy. A case study

To be, or not to be… Guillain-Barré Syndrome

Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Physical therapy management for conversion disorder: case series

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.

Psychogene Lähmungen im Kindes- und Jugendalter

Zusammenfassung: Am Beispiel vorliegender klinischer Studien aus der Literatur werden die Charakteristika der psychogenen Lähmung im Kindes- und Jugendalter erarbeitet. Anhand einer Übersicht wird zunächst der Wandel in der diagnostischen Einordnung der psychogenen Lähmung von der ICD-6 bis zur ICD-10 dargestellt. Weiterhin werden die epidemiologischen Daten aus der Literatur referiert. Die psychogene Lähmung bei Kindern und Jugendlichen zeigt innerhalb der dissoziativen Störungen in dieser Altersgruppe eine charakteristische Alters- und Geschlechtsverteilung, sowie eine gute Prognose. Eine besondere Rolle für die Genese der psychogenen Lähmungen und Gangstörungen spielen invasive iatrogene diagnostische und therapeutische Eingriffe, körperliche Traumata, Infekterkrankungen und Modellerkrankungen.

A management model for pediatric somatization

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

Case study: negative reinforcement and behavioral management of conversion disorder

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

Behavioral management of conversion disorder in children

OBJECTIVE

To describe the behavioral management of conversion disorder in children and to preliminarily assess its effectiveness.

DESIGN

Retrospective case series.

SETTING

Inpatient pediatric rehabilitation unit.

PATIENTS

The first eight patients with conversion disorder treated on our pediatric rehabilitation unit, between 9 and 18 years of age. Six were girls. Three cases are described in detail.

INTERVENTIONS

All patients were treated as inpatients, using a behavioral approach. Inadvertent reinforcement of illness behavior was identified, and a reward system was established for good attainment. Some patients had a "level" system instituted, with increasing privileges for goal achievement. All patients and their families had psychological assessment and instruction in pain and stress management strategies.

MAIN OUTCOME MEASURES

Restoration of normal gait and function, independence in activities of daily living (ADL), and symptom recurrence after discharge.

RESULTS

All patients attained normal gait and ADL function before discharge.

CONCLUSIONS

(1) Behavioral management of conversion disorder in children appears to be as effective as in adults, although at times a behavioral reward or "level" system may be necessary for adequate reinforcement. (2) Instruction of the patient and family in appropriate stress and pain management appears key to maintaining treatment effect over time.

Somatization in children and adolescents

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

This paper describes the brief in-patient treatment of two adolescents with hysterical conversion disorder. It is unique in that treatment was conducted on a general medical/surgical service. Although operantly based, the treatment utilized biofeedback and measurable psychophysiological changes as criteria to obtain reinforcement. The advantages of this approach to both patient and hospital staff are discussed.