Management of children with non-organic (hysterical) disorders of motor function

Scoping review and expert-based consensus recommendations for assessment and management of psychogenic non-epileptic (functional) seizures (PNES) in children: A report from the Pediatric Psychiatric Issues Task Force of the International League Against Epilepsy

Limited guidance exists regarding the assessment and management of psychogenic non-epileptic seizures (PNES) in children. Our aim was to develop consensus-based recommendations to fill this gap. The members of the International League Against Epilepsy (ILAE) Task Force on Pediatric Psychiatric Issues conducted a scoping review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SR) standards. This was supplemented with a Delphi process sent to pediatric PNES experts. Consensus was defined as ≥80% agreement. The systematic search identified 77 studies, the majority (55%) of which were retrospective (only one randomized clinical trial). The primary means of PNES identification was video electroencephalography (vEEG) in 84% of studies. Better outcome was associated with access to counseling/psychological intervention. Children with PNES have more frequent psychiatric disorders than controls. The Delphi resulted in 22 recommendations: Assessment-There was consensus on the importance of (1) taking a comprehensive developmental history; (2) obtaining a description of the events; (3) asking about potential stressors; (4) the need to use vEEG if available parent, self, and school reports and video recordings can contribute to a "probable" diagnosis; and (5) that invasive provocation techniques or deceit should not be employed. Management-There was consensus about the (1) need for a professional with expertise in epilepsy to remain involved for a period after PNES diagnosis; (2) provision of appropriate educational materials to the child and caregivers; and (3) that the decision on treatment modality for PNES in children should consider the child's age, cognitive ability, and family factors. Comorbidities-There was consensus that all children with PNES should be screened for mental health and neurodevelopmental difficulties. Recommendations to facilitate the assessment and management of PNES in children were developed. Future directions to fill knowledge gaps were proposed.

Psychologically Informed Physical Therapy for Children and Adolescents With Functional Neurological Symptoms: The Wellness Approach

Children with functional neurological disorder (FND) present with motor and sensory neurological symptoms that impair health and physical functioning and that create an ongoing clinical burden for caregivers and hospitals worldwide. Treatment programs for these children involve a multidisciplinary approach with physical therapy as a fundamental component. However, standard musculoskeletal approaches to physical therapy are ineffective or may even exacerbate symptoms because they are unresponsive to the biopsychosocial context in which FND emerges: FND typically occurs in the context of stress, either physical or emotional; symptoms are amplified by attention; and presentations are complicated by psychological factors. Informed, in part, by published guidelines for physical therapy with adult FND patients, this article examines common challenges that arise when working with children: overcoming previous negative encounters in the medical system; avoiding amplification of symptoms by drawing attention to them; and managing comorbid pain, falls, faints, nonepileptic seizures, dizziness, fatigue, and breathlessness, plus psychological symptoms such as anticipatory anxiety and panic attacks. What emerges is a psychologically informed therapeutic approach to physical therapy for children with functional neurological symptoms. This approach prioritizes interpersonal processes and physical therapy techniques that establish a therapeutic relationship and create a safe space for physical therapy, that use indirect physical therapy approaches redirecting the focus of attention away from symptoms and emphasizing the completion of tasks and activities engaging the sick body part indirectly, that tailor the intervention to address the needs and presentation of each particular child, and that integrate psychological interventions to manage common challenges.

Psychologically informed physiotherapy as part of a multidisciplinary rehabilitation program for children and adolescents with functional neurological disorder: Physical and mental health outcomes

AIM

Children and adolescents with functional neurological disorder (FND) present with physical impairment and mental health comorbidities. Specialist physiotherapy programs for treating FND have been developed over the last two decades. This article reports outcome data from three cohorts of children treated with a multidisciplinary rehabilitation intervention - the Mind-Body Program - in which a psychologically informed physiotherapy intervention, known as the wellness approach to physiotherapy, was a key component.

METHODS

For three cohorts of children (n = 57, n = 60 and n = 25, respectively) treated in the Mind-Body Program, data about functional impairment and mental health concerns were collected at presentation and at follow-up (4 years, 12 months and 18 months, respectively).

RESULTS

Outcome data show that FND symptoms resolved in 54/57 (95%), 51/60 (85%) and 22/25 (88%) of children in the three cohorts, and that 31/57 (61%), 32/60 (53%) and 13/25 (52%) of children returned to full health and to full-time school attendance. Changes in Global Assessment of Function (GAF) were significant (t(54) = 21.60, P < 0.001; t(55) = 9.92, P < 0.001; t(24) = 6.51, P < 0.001). Outcomes were less favourable for children with chronic FND symptoms at presentation; those whose comorbid mental health disorders or other (comorbid) functional somatic symptoms did not resolve; and those who subsequently developed chronic mental health problems.

CONCLUSIONS

Implementation of a multidisciplinary rehabilitation intervention - with psychologically informed physiotherapy as one of the key treatment components - resulted in resolution of FND symptoms and return to health and well-being in the large majority of patients.

Somatising in children and adolescents. 2. Management and outcomes

In this paper I outline the assessment, engagement and management of children and adolescents with somatising conditions. The major diagnostic groups, in rough order of prevalence, are adjustment, dissociative (transient and chronic), somatoform and factitious disorders and chronic fatigue. See Eminson (2001) for more detailed descriptions and subtypes.

Fifteen-minute consultation: Medically unexplained symptoms

Medically unexplained symptoms are common and not always easy to manage. A wide range of symptoms may be presented and anxiety in the child, family and paediatrician about the possibility of a missed serious organic diagnosis may hamper effective management. Evidence-based approaches to a number of different presenting problems share a number of components. A model for assessment and management based on clinical experience and this evidence base is described.

Is physiotherapy effective in the management of child and adolescent conversion disorder? A systematic review

Child and adolescent conversion disorder has the potential to impart significant burden on health-care services and affect quality of life. Clinically, physiotherapists are involved in conversion disorder management; however, no systematic reviews have examined physiotherapy effectiveness in its management. The aim of this review is to identify the efficacy of physiotherapy management of child and adolescent conversion disorder. A search of multiple databases (Medline, CINAHL, Embase, PsychINFO, PEDro and the Cochrane Library) was completed along with manual searching of relevant reference lists to identify articles including children 0-18 years with a diagnosis of conversion disorder who received physical management. Two independent reviewers screened titles and abstracts using criteria. Data were extracted regarding study characteristics, functional outcome measures, length of stay, physiotherapy service duration and resolution of conversion symptoms. Methodological quality was assessed using a tool designed for observational studies. Twelve observational studies were included. No functional outcome measures were used to assess the effectiveness of the treatment protocols in the case studies. Resolution of symptoms occurred in all but two cases, with conversion symptoms still present at 11 months and at 2 years. Length of stay varied from 3 days to 16 weeks, with similar variation evident in length of physiotherapy service provision (2.5 weeks to 16 weeks). There was limited and poor quality evidence to establish the efficacy of physiotherapy management of child and adolescent conversion disorders. More rigorous study designs with consistent use of reliable, valid and sensitive functional outcome measures are needed in this area.

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.

Subconscious guided therapy with hypnosis

Two adolescents were hospitalized with incapacitating symptoms: one with headache, back pain, and an inability to walk, while the other had headache, musculoskeletal pain, nausea, and emesis. Medical evaluation did not reveal an etiology for the symptoms of either patient. Consultation with child psychiatry services yielded recommendations that both patients might benefit from counseling. Both demonstrated an immediate improvement of their symptoms with instruction in self-hypnosis-induced relaxation techniques that included favorite place imagery and progressive relaxation. The patients were told that while in hypnosis their "subconscious" might be able to characterize psychological issues that underlay their symptoms through the medium of automatic word processing (AWP). The information identified through AWP helped guide their subsequent therapy. Thus, instruction in self-hypnosis, as well as helping adolescents develop awareness about the cause of their debilitating symptoms can be associated with rapid improvement of their symptoms.

Urinary retention, erectile dysfunction and penile anaesthesia after circumcision: a mixed dissociative (conversion) disorder

We report on the long-term followup of a mixed dissociative (conversion) disorder after circumcision in childhood.

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.

Psychogenic equinovarus: the importance of recognition and non-operative treatment

Although the potential for musculoskeletal symptoms in hysteric conversion disorder was recognized by Sigmund Freud, reports of it in the orthopaedic literature have been limited to upper extremity manifestations. This study reports 3 cases which illustrate hysteric conversion presenting as primary foot and ankle complaints. Given its relative rarity, it is a diagnosis that is easy to miss. Clinical clues to its diagnosis and accepted methods of treatment are discussed. It is important to realize that this condition arises from an unconscious conflict and does not represent a voluntary falsification of symptoms. As such, confrontational treatment is not generally successful.

Diagnosis and rehabilitation strategies for patients with hysterical hemiparesis: a report of four cases

Conversion disorder is a psychological disturbance that produces subconscious alterations in sensorimotor function. Hysterical hemiparesis is a relatively rare, and difficult to diagnose, form of conversion disorder presenting as unilateral motor weakness with or without sensory deficits. We report four patients who required inpatient rehabilitation for hysterical hemiparesis, a diagnosis for which there is little information regarding rehabilitation management. In all cases, an extensive acute care evaluation including multiple imaging studies failed to identify a new neurologic lesion. All patients had rapid functional improvement using functional and behavioral therapies and extensive psychosocial support (mean length of stay of 11 days; mean Functional Independence Measure [FIM] gain of 22; mean discharge FIM of 112), consistent with other published reports of rehabilitation of conversion disorder. Evaluation of these cases reveals consistencies regarding presentation, psychosocial history, and rehabilitation course that can aid clinicians in making the diagnosis. Rehabilitation strategies for hysterical hemiparesis are reviewed.

Behavioral treatment of conversion disorder in adolescence. A case example of Globus Hystericus

The present single case study evaluated the efficacy of a cognitive-behavioral intervention for the treatment of a patient diagnosed with globus hystericus, a conversion disorder characterized by a perceived lump in the throat. The patient was a non-mentally retarded 12-year-old female who refused to swallow solids because she thought that her throat muscles would involuntarily constrict and result in choking. She lost approximately .5 lbs. per week during the 6 months prior to treatment. Improvements in weight gain were demonstrated consequent to the implementation of behavior therapy, with weight gain being particularly pronounced after contingency contracting was added to therapy. Weight gain was maintained at 1, 6, and 10 months posttreatment.

Somatisation in children

This review summarises recent work on somatisation in childhood. Minor physiological dysfunction may play a part in a number of cases and associated psychiatric disorders are commonly though not universally found. Contributory family factors include high rates of health problems and of parental psychological distress and there is some evidence for the role of family modelling and reinforcement of illness behaviour. There is suggestive evidence linking somatisation to emotional closeness in families, to family togetherness around health matters and to anomalies in children's social relationships. Somatisation in children can respond to treatments involving cognitive-behavioural and family techniques as well as to sensitive, psychologically sound advice from paediatricians.

Dopa responsive dystonia

There may be insufficient awareness of dopa responsive dystonia (DRD), which has a characteristic diurnal variation of symptoms. Two children are reported in whom the diagnosis of DRD was missed. The first was thought to have hysteria and the second hereditary spastic paraparesis. A full history is vital for the diagnosis of this important treatable syndrome.

Intractable sneezing as a conversion symptom

A literature review of reported cases of intractable sneezing reveals that intractable sneezing typically occurs in children or adolescents and is a manifestation of conversion disorder. Analysis of these cases demonstrates a number of features that are helpful in differentiating psychogenic from organic sneezing. Also discussed are aspects of patient management once a diagnosis of conversion disorder is established.

Emergency department presentation of patients with conversion disorder

OBJECTIVE

To describe the presenting symptoms and other features of ED patients diagnosed as having conversion disorder.

METHODS

A retrospective chart review was carried out on the records of ED patients who had had final ED or in-hospital diagnoses of conversion disorder. Cases from 1982 to 1992 at a 566-bed rural tertiary care hospital with a residency program in emergency medicine were reviewed for patient age and gender, presenting signs and symptoms, ED diagnostic evaluation, disposition, and comorbidity.

RESULTS

Of 42 patients who had conversion disorder diagnoses, 24 were women and 18 were men. Twenty-one (50%) of the patients were diagnosed in the ED, and of those patients, ten were released home from the ED. Patient age ranged from 5 to 70 years, with a mean age of 33 years for women and 34 years for men. Most clinical symptoms mimicked neurologic disorder (weakness, pain, seizure-like activity, loss of consciousness, etc). Thirty patients (71%) received laboratory studies in the ED and two others received laboratory studies on admission. Seventeen (40%) patients had computed tomography of the head and five (12%) patients had magnetic resonance imaging of the head. Twelve (29%) patients had previous histories of psychiatric disorders, four (10%) had histories of alcohol and drug abuse, two (5%) had prior conversion reactions, three (7%) had chronic illnesses, and four (10%) had been victims of previous head trauma.

CONCLUSION

Patients with conversion disorder in the ED usually present with neurologic symptoms and undergo multiple diagnostic tests. Comorbidity is common. Early psychiatric evaluation may assist in the diagnosis and evaluation of patients with suspected conversion disorder in the ED.

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 disorder, sexual abuse and interprofessional communication – some lessons to be re-learned

We describe an adolescent boy who presented with physical symptoms, for which no organic cause could be found. He proved a challenge to medical management and we highlight the reluctance to consider making a diagnosis of conversion disorder. Significant medical contact since infancy, a history of sexual abuse, and current stressors are considered as having contributed to his presentation. We discuss general issues in the management of conversion disorder and consider the risks of neglecting this diagnosis as technological advances are made and sophisticated investigations are relied upon.

Recent developments in the understanding of paediatric musculoskeletal pain syndromes

Images

A selective review of child psychiatric syndromes with a somatic presentation

This review focuses on 'aches and pains' and conversion syndromes as a basis for the description of psychological factors and mechanisms of relevance for the somatisation of distress in childhood and which may contribute to medical help-seeking for children. The characteristic pattern of associated psychological factors includes child personality features; academic concerns; family health problems; and styles of family interaction. Further research is required to explore in more depth the nature of these factors, the mechanisms that mediate the development of severe handicapping problems, and effective interventions.

An integrated medical and psychiatric approach to conversion symptoms in a four-year-old

Conversion disorder is a challenging diagnosis in children and adolescents. Medical and psychiatric diagnoses need to be evaluated both separately and in relation to each other. This case highlights both the diagnostic criteria for a conversion disorder in a young child and the need for an integrated medical and psychiatric approach by physicians.

Severe chronic fatigue syndrome in chidhood: A discussion of psychopathological mechanisms

Severe chronic fatigue syndromes are rare in childhood. Two severely affected children are described, one presenting in an extreme withdrawal state. Possible psychopathological mechanism are discussed including the relevance of viral illnesses, depressive symptoms, characteristic child personality and family relationship. These mechanisms are comparable to those described for other functional somatic problems of childhood, suggesting their general relevance in the maintenance of the somatization of distress in childhood. Treatment strategies are described which resulted in recovery in both cases.

Conversion disorders in childhood: a retrospective follow-up study of 84 inpatients

The medical histories of 84 children who had been diagnosed as having conversion disorder were reviewed in a follow-up study, and the validity of this diagnosis was examined. The female:male ratio was 2.1:1, although below the age of 10 the ratio was almost equal. The medical histories of 62 per cent of the patients showed an organic illness, and 51 per cent had various slight to moderate EEG disturbances. The validity of the diagnosis was very high: only five were found to have organic disease during the follow-up period. Children with symptoms of conversion disorder should receive appropriate medical investigations, but the authors question whether extensive investigations could not be replaced by screening tests, combined with early psychiatric intervention.

Hysteria, belief, and magic

“We cannot command nature except by obeying her” (Bacon)

Diagnosis and treatment of hysterical conversion reactions

Twenty children with hysterical conversion reactions were reviewed. The ways in which they became ill, the attitudes of their families to their illnesses and their underlying personal problems were noted. Treatment comprised avoiding unnecessary investigations and removing symptoms by using graded exercises given by physiotherapists. Exploration of the underlying psychological problems took place at a pace with which the family could cope because many families were reluctant at first to accept that the illness was psychological. Seventeen of the 20 children recovered completely within three months of starting treatment. The results show that early diagnosis and close liaison between paediatricians, physiotherapists, and child psychiatrists are necessary if prolonged handicap is to be avoided.

Clinical features of conversion disorder

This study reviewed the case notes of 52 children diagnosed as suffering from hysterical conversion during admission to a paediatric teaching hospital over a 10 year period. The disorder was rare below 8 years of age and girls outnumbered boys three to one. Altogether 75% of the children presented during spring and summer; at the time of end of year exams and the beginning of the new school year. The presentation was usually polysymptomatic with gait disturbance being the main complaint in 36 children. Sensory abnormality, predominantly pain, was present in 40 children; this indicates a strong association between psychogenic pain and conversion disorder in children. At discharge 32 were completely recovered or had appreciably improved. There was a core group that presented particular difficulties with diagnosis and showed little positive response to treatment.

Diagnosis of functional illness presenting with gait disorder

Nine children presented with disturbances of gait that were not caused by organic disease. They all fulfilled at least four out of eight diagnostic criteria. Diagnosis in all had been delayed while organic causes were excluded. Unnecessary and sometimes potentially harmful procedures were performed or proposed for each child. Identification of such children earlier may avoid morbidity and facilitate management.

Hysteria, play-acting and courage

Levi-Strauss (1977) describes what happened to a child, in a primitive tribe, accused of sorcery–a crime punishable by death. The child invented more and more complex stories by way of self-justification. In the end his accusers believed his outlandish explanation because “the choice is not between this system and another but between this system and no system at all-chaos.” The child's plight can represent the close affinity between magic and hysteria; his accusers might represent those contemporary psychiatrists who would prefer any system of classification of hysteria, however absurd, to no system at all (Sheehan & Sheehan, 1982a, b; DSM-III, 1980).

Management of conversion reaction in five adolescent girls

Hysteria is a topic which has produced a plethora of articles on adults but, in comparison, there is a scarcity when it involves children and young adolescents. There is considerable confusion in definition, classification, incidence and management. More agreement seems to be found when conversion reactions are specifically considered. This article attempts to present the dilemma that confronts the clinician when faced with an individual patient with a conversion reaction. This may especially apply to the present day practitioner who is likely not to have had much personal experience in managing this condition. Some of the relevant literature is summarized and the five patients are presented in tabular form and individually, together with their outcome at follow-up. The findings are discussed and some conclusions are drawn.

Limb pain in childhood

As the presenting complaint in 7 per cent of pediatrician visits, pain in the limbs is a common problem in childhood. It is important that the diagnosis be made expeditiously. The authors review the possible organic cause of limb pain, as well as limb pain from conversion reactions and from growing pains, giving special attention to the differential diagnosis so that appropriate treatment for the pain can be initiated.