Conversion disorder in children and adolescents: A disorder of cognitive control

Recent advances in understanding the neurobiology of pediatric functional neurological disorder

INTRODUCTION

Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and up to 20% of adolescents admitted to hospital for the management of intractable seizures.

AREAS COVERED

The current review focuses on the neurobiology of pediatric FND. The authors present an overview of the small but growing body of research pertaining to the biological, emotion-processing, cognitive, mental health, physical health, and social system levels.

EXPERT OPINION

Emerging research suggests that pediatric FND is underpinned by aberrant changes within and between neuron-glial (brain) networks, with a variety of factors - on multiple system levels - contributing to brain network changes. In pediatric practice, adverse childhood experiences (ACEs) are commonly reported, and activation or dysregulation of stress-system components is a frequent finding. Our growing understanding of the neurobiology of pediatric FND has yielded important flow-on effects for assessing and diagnosing FND, for developing targeted treatment interventions, and for improving the treatment outcomes of children and adolescents with FND.

Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment

Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.

Objective and subjective neurocognitive functioning in functional motor symptoms and functional seizures: preliminary findings

INTRODUCTION

This study aimed to provide a preliminary assessment of objective and subjective neurocognitive functioning in individuals with functional motor symptoms (FMS) and/or functional seizures (FS). We tested the hypotheses that the FMS/FS group would display poorer objective attentional and executive functioning, altered social cognition, and reduced metacognitive accuracy.

METHOD

Individuals with FMS/FS (n = 16) and healthy controls (HCs, n = 17) completed an abbreviated CANTAB battery, and measures of intellectual functioning, subjective cognitive complaints, performance validity, and comorbid symptoms. Subjective performance ratings were obtained to assess local metacognitive accuracy.

RESULTS

The groups were comparable in age (p = 0.45), sex (p = 0.62), IQ (p = 0.57), and performance validity (p-values = 0.10-0.91). We observed no impairment on any CANTAB test in this FMS/FS sample compared to HCs, although the FMS/FS group displayed shorter reaction times on the Emotional Bias task (anger) (p = 0.01, np2 = 0.20). The groups did not differ in subjective performance ratings (p-values 0.15). Whilst CANTAB attentional set-shifting performance (total trials/errors) correlated with subjective performance ratings in HCs (p-values<0.005, rs = -0.85), these correlations were non-significant in the FMS/FS sample (p-values = 0.10-0.13, rs-values = -0.46-0.50). The FMS/FS group reported more daily cognitive complaints than HCs (p = 0.006, g = 0.92), which were associated with subjective performance ratings on CANTAB sustained attention (p = 0.001, rs = -0.74) and working memory tests (p < 0.001, rs = -0.75), and with depression (p = 0.003, rs = 0.70), and somatoform (p = 0.003, rs = 0.70) and psychological dissociation (p-values<0.005, rs-values = 0.67-0.85).

CONCLUSIONS

These results suggest a discordance between objective and subjective neurocognitive functioning in this FMS/FS sample, reflecting intact test performance alongside poorer subjective cognitive functioning. Further investigation of neurocognitive functioning in FND subgroups is necessary.

Myths and facts about functional neurological disorders: a cross-sectional study of knowledge and awareness among medical students and healthcare professionals in Iraq

Background

Functional neurological disorder (FND) is a complex condition with neurological symptoms but no clear structural or biochemical explanation. Myths and misconceptions about FND can lead to misdiagnosis and inappropriate treatment. This study aimed to assess knowledge and common myths about FND among medical students and practitioners.

Methods

Data were collected from 324 participants using a structured questionnaire. The questionnaire included demographics, general information about FND and myths about FND. Data were analysed using non-parametric tests and Spearman's r for correlations.

Results

The majority of participants were clinical-years medical students (65.1%) and female (59.6%). Overall, knowledge about FND was limited, with a mean score of 42.3% of correct answers. Common myths included the belief that FND is a psychological disorder and that patients feign symptoms. Knowledge scores differed significantly among different grades/experience levels, with postgraduate practitioners having the highest scores. There was a positive correlation between knowledge scores and confidence in managing FND.

Conclusion

This study highlights the prevalence of myths and misconceptions about FND among medical students and practitioners, emphasising the need for accurate education to improve diagnosis and management. Healthcare professionals should take a biopsychosocial approach to FND, considering the complex interplay between biological, psychological and social factors. Efforts to increase awareness and reduce stigma associated with FND are crucial for promoting better care. Targeted educational interventions may be beneficial to improve the understanding and management of FND among medical professionals.

Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report

INTRODUCTION

Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it.

METHODS

We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel.

RESULTS

All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed.

CONCLUSION

The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.

Psychiatrists' attitudes towards functional neurological disorders: results from a national survey

Introduction

Functional neurological disorder (FND) presents motor, sensory, and cognitive symptoms characterized by clinical signs incongruent with known neurological disease. Together with other health professionals, like neurologists, psychiatrists can play an essential role in diagnosing and managing these disorders. Hence, understanding their opinion and clinical experience with FND is of utmost importance to catch potential educational needs and improve healthcare services for patients. This study aims at assessing the knowledge, opinion, and clinical approach of Italian psychiatrists to FND.

Methods

Members of the Italian Society of Psychiatry completed a 14-item web-based survey investigating their approach to FND. Results. Overall, 174 questionnaires were completed. Our main findings suggest that Italian psychiatrists have a psychogenetic conceptualization of FND. "Conversion disorders", in fact, is the term most frequently used by Italian psychiatrists to refer to FND, thus implying a psychological etiology of these disorders. Congruently with this view, psychotherapy associated with pharmacological therapy is considered the most appropriate treatment by psychiatrists, while physiotherapy is an under-recognized treatment option for FND.

Discussion

The present study highlights that a psychogenetic view of FND dominates among Italian psychiatrists. This could be due to out-of-date knowledge about the pathophysiology of this group of disorders. Promoting education about novel approaches to FND would be of crucial importance to improving care for patients suffering from this condition.

[Understanding functional neurological disorders: From biological markers to pathophysiological models]

OBJECTIVES

Functional neurological disorders have witnessed intense research activity in the fields of structural and functional neuroimaging for more than twenty years. Thus, we propose a synthesis of recent research findings and etiological hypotheses that have been proposed so far. This work should help clinicians to better understand the nature of the mechanisms involved, but also help patients to increase their knowledge about the biological features underlying their functional symptoms.

METHODS

We carried out a narrative review of international publications dealing with neuroimaging and biology of functional neurological disorders, from 1997 to 2023.

RESULTS

Several brain networks underlie functional neurological symptoms. These networks play a role in the management of cognitive resources, in attentional control, emotion regulation, in agency and in the processing of interoceptive signals. The mechanisms of the stress response are also associated with the symptoms. The biopsychosocial model helps to better understand predisposing, precipitating, and perpetuating factors involved. The functional neurological phenotype results from the interaction between: i) a specific pre-existing vulnerability resulting from biological background and epigenetic modifications, and ii) exposure to stress factors, according to the stress-diathesis model. This interaction causes emotional disturbances including hypervigilance, lack of integration of sensations and affects, and emotional dysregulation. These characteristics in turn impact the cognitive, motor and affective control processes related with the functional neurological symptoms.

CONCLUSIONS

A better knowledge of the biopsychosocial determinants of brain network dysfunctions is necessary. Understanding them would help developing targeted treatments, but is also critical for patients care.

The importance of organic screening, regarding a clinical case

INTRODUCTION

Before cataloguing a morbid process as a "mental disorder", it is essential to bear in mind the importance of early diagnosis of causes of non-psychiatric origin for a possible clinical presentation. For this reason, we will try to reflect this fact, which it seems necessary to remember even though it is well known, since it can be overlooked in emergency situations in the hospital setting, with the consequences derived from an incomplete diagnosis and with the potential life-threatening risk for the patient.

CASE PRESENTATION

A 13-year-old female adolescent, who presented an acute clinical picture suggestive of dissociative disorder. She required hospital admission for diagnostic-therapeutic clarification, and neuroimaging findings led to an initial diagnosis of a neoplastic lesion in the brain stem and, finally, as ischaemic lesion of vasculitic origin in said location.

DISCUSSION

A differential diagnosis was proposed through the different psychic and non-psychic aetiologies of the clinical picture, but the intervention of the hospital's paediatric service was necessary for orientation and definitive affiliation, given the suspicion of non-psychiatric illness after a torpid evolution in spite of psychotherapeutic and psychopharmacological interventions.

CONCLUSIONS

Through the presentation and review of a clinical case that happened in our hospital, we must insist on an adequate comprehensive approach to the patient, especially with the child-adolescent population, when faced with an acute clinical presentation and without previous studies at a relevant physical level.

The neurobiology of functional neurological disorders characterised by impaired awareness

We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.

Clinical and psychopathological profiles of children with somatic symptom disorders in a pediatric emergency unit: an observational study before and during the SARS-CoV-2 pandemic

Somatic symptom disorders (SSDs) are a group of clinical conditions characterized by heterogeneous physical symptoms, not directly supported by a demonstrable organic process. Despite representing a growing problem in the pediatric age, the literature lacks studies assessing the psychopathological and clinical features of subjects with SSD, particularly during the SARS-CoV-2 pandemic. This is a retrospective, observational study, involving two historical cohorts of children admitted to a tertiary referral Italian hospital over the 2 years preceding and following the start of the SARS-CoV-2 pandemic. Demographic, clinical, socio-economical, and psychological variables were investigated. Standardized tests for the developmental age were administered to assess psychopathological variables. Overall rates and trends of accesses for SSD, as compared to the total accesses for any cause at the Pediatric Emergency Room during the same periods, were reported as well. Fifty-one (pre-pandemic, 29; pandemic, 22) children with SSD were enrolled (age, 11.4 ± 2.4 years, F = 66.7%). Subjects in the pandemic historical cohort reported more frequently fever (p < 0.001), headache (p = 0.032), and asthenia (p < 0.001), as well as more chronic conditions in personal and family history, and fewer previous hospital accesses, as compared to the pre-pandemic cohort. Depressed mood and anxious traits were documented in both samples. None of them had an ongoing or a previously reported SARS-CoV-2 infection. During the pandemic, a clinical psychologist was more frequently consulted before the hospital discharge to mental health services, to support the diagnosis.  Conclusion: This study showed the significant burden of SSD in children, highlighting the need to implement pediatricians' education to optimize the management of these patients. Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features. Future studies, conducted on longitudinal and controlled samples, are indicated to further investigate children with these conditions. What is Known:    • Somatic symptoms disorders (SSDs) are frequent in the pediatric age, especially in early adolescence.    • Evidence remains scarce on the impact of the SARS-CoV-2 pandemic on SSDs in children. What is New:    • Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features.    • The implementation of pediatricians' education and a multidisciplinary approach are needed to optimize the management of SSDs.

Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study

PURPOSE

To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development.

METHODS

Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS.

RESULTS

Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms.

CONCLUSION

Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.

Altered resting-state neural networks in children and adolescents with functional neurological disorder

•

FND in children commonly involves presentation with multiple neurological symptoms.

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Children with FND show wide-ranging connectivity changes in resting-state neural networks.

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Aberrant neural-networks changes are greater in children whose FND includes functional seizures.

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Subjective distress, autonomic arousal, and HPA dysregulation contribute to network changes.

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Children with FND (vs controls) report more subjective distress and more ACEs across the lifespan.

Objectives

Previous studies with adults suggest that aberrant communication between neural networks underpins functional neurological disorder (FND). The current study adopts a data-driven approach to investigate the extent that functional resting-state networks are disrupted in a pediatric mixed-FND cohort.

Methods

31 children with mixed FND and 33 age- and sex-matched healthy controls completed resting-state fMRI scans. Whole-brain independent component analysis (pFWE < 0.05) was then used to identify group differences in resting-state connectivity. Self-report measures included the Depression, Anxiety and Stress Scale (DASS-21) and Early Life Stress Questionnaire (ELSQ). Resting-state heart rate (HR) and cortisol-awakening response (CAR) were available in a subset.

Results

Children with FND showed wide-ranging connectivity changes in eight independent components corresponding to eight resting-state neural networks: language networks (IC6 and IC1), visual network, frontoparietal network, salience network, dorsal attention network, cerebellar network, and sensorimotor network. Children whose clinical presentation included functional seizures (vs children with other FND symptoms) showed greater connectivity decreases in the frontoparietal and dorsal attentional networks. Subjective distress (total DASS score), autonomic arousal (indexed by HR), and HPA dysregulation (attenuated/reversed CAR) contributed to changes in neural network connectivity. Children with FND (vs controls) reported more subjective distress (total DASS score) and more adverse childhood experiences (ACEs) across their lifespan.

Conclusions

Children with FND demonstrate changes in resting-state connectivity. Identified network alterations underpin a broad range of functions typically disrupted in children with FND. This study complements the adult literature by suggesting that FND in children and adolescents emerges in the context of their lived experience and that it reflects aberrant communication across neural networks.

Executive Functions and Attention in Patients With Psychogenic Nonepileptic Seizures Compared With Healthy Controls: A Cross-Sectional Study

OBJECTIVE

Psychogenic nonepileptic seizures (PNESs) are considered functional neurological symptoms and are highly prevalent in specialized epilepsy clinics. The underlying mechanisms of PNES are not fully understood. Recent findings point toward possible alterations in attention and executive functions. This study aimed to extend the current knowledge of attention and executive function in patients with PNES and to assess possible relationships between seizures and dissociation, childhood trauma, and cognitive function.

METHODS

We recruited 40 patients with PNES and 40 sex-, age-, and education-matched healthy controls (HCs) in this study. Participants completed self-report questionnaires to assess early life stress (Childhood Trauma Questionnaire [CTQ]), dissociation (the German version of the Dissociative Experience Scale, or Fragebogen zu dissoziativen Symptomen), and depression (Patient Health Questionnaire-9). Executive functions and attention were assessed with the Trail Making Test (TMT), Digit Span, and Attention Network Task.

RESULTS

Compared with HCs, patients with PNES reported significantly higher levels of childhood trauma, depression, and dissociation. Patients with PNES also had reduced performance indices for Digit Span Forward (d = 0.62), Digit Span Backward (d = 0.62), and TMT (d = 0.67) but not Attention Network Task. CTQ scores positively correlated with TMT and Digit Span Backward performance in patients with PNES. Adjusting for CTQ scores attenuated the observed group difference in TMT performance. Depression and dissociation did not explain the observed findings.

CONCLUSIONS

These results contribute to the evidence of impaired executive functions in patients with PNES. Furthermore, childhood trauma scores, but not (trait) dissociation or depression scores, seem to drive group differences (HC versus patients with PNES).

["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]

OBJECTIVES

Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents.

METHODS

The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis.

RESULTS

A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented.

CONCLUSIONS

Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.

The importance of organic screening, regarding a clinical case

INTRODUCTION

Before cataloguing a morbid process as a "mental disorder", it is essential to bear in mind the importance of early diagnosis of causes of non-psychiatric origin for a possible clinical presentation. For this reason, we will try to reflect this fact, which it seems necessary to remember even though it is well known, since it can be overlooked in emergency situations in the hospital setting, with the consequences derived from an incomplete diagnosis and with the potential life-threatening risk for the patient.

CASE PRESENTATION

A 13-year-old female adolescent, who presented an acute clinical picture suggestive of dissociative disorder. She required hospital admission for diagnostic-therapeutic clarification, and neuroimaging findings led to an initial diagnosis of a neoplastic lesion in the brain stem and, finally, as ischaemic lesion of vasculitic origin in said location.

DISCUSSION

A differential diagnosis was proposed through the different psychic and nonpsychic aetiologies of the clinical picture, being the intervention of the hospital's paediatric service necessary for orientation and definitive affiliation, given the suspicion of non-psychiatric illness after a torpid evolution in spite of psychotherapeutic and psychopharmacological interventions.

CONCLUSIONS

Through the presentation and review of a clinical case that happened in our hospital, we must insist on an adequate comprehensive approach to the patient, especially with the child-adolescent population, when faced with an acute clinical presentation and without previous studies at a relevant physical level.

Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation

The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.

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.

Psychogenic Pseudosyncope: Clinical Features, Diagnosis and Management

Psychogenic Pseudosyncope (PPS) is the appearance of Transient Loss of Consciousness (TLOC) in which movements are absent, but there are no hemodynamic and electroencephalographic modifications as are induced by gravitational challenges which characterize syncope and true loss of consciousness. For younger and adult populations, a detailed history is crucial for the diagnosis. Clinical clues that should raise the suspicion for PPS include prolonged duration of the LOC, eye closure during the episode, unusual triggers, no recognizable prodromes and the high frequency of attacks. The presence of an established diagnosis of syncope should not deter from the concomitant diagnosis of PPS. The gold standard for a proper diagnosis of PPS is the documentation by a tilt test of normal hemodynamic and electroencephalographic parameters, when recorded during an attack. Treatment of PPS, based on the clear and empathetic communication of the diagnosis, can lead to an immediate reduction of attack frequency and lower the need to call on emergency services. Pharmacological treatment of associated psychiatric disorders and psychological interventions may be beneficial in patients with PPS. Cognitive-behavioural therapy holds the most reliable evidence of efficacy. In the present review, we aimed to address PPS with historical aspects, main clinical features and diagnostic tests, current diagnostic classification, underlying neurobiological abnormalities, management and therapy.

Activation of Functional Brain Networks in Children With Psychogenic Non-epileptic Seizures

Objectives

Psychogenic non-epileptic seizures (PNES) have been hypothesized to emerge in the context of neural networks instability. To explore this hypothesis in children, we applied a graph theory approach to examine connectivity in neural networks in the resting-state EEG in 35 children with PNES, 31 children with other functional neurological symptoms (but no PNES), and 75 healthy controls.

Methods

The networks were extracted from Laplacian-transformed time series by a coherence connectivity estimation method.

Results

Children with PNES (vs. controls) showed widespread changes in network metrics: increased global efficiency (gamma and beta bands), increased local efficiency (gamma band), and increased modularity (gamma and alpha bands). Compared to controls, they also had higher levels of autonomic arousal (e.g., lower heart variability); more anxiety, depression, and stress on the Depression Anxiety and Stress Scales; and more adverse childhood experiences on the Early Life Stress Questionnaire. Increases in network metrics correlated with arousal. Children with other functional neurological symptoms (but no PNES) showed scattered and less pronounced changes in network metrics.

Conclusion

The results indicate that children with PNES present with increased activation of neural networks coupled with increased physiological arousal. While this shift in functional organization may confer a short-term adaptive advantage-one that facilitates neural communication and the child's capacity to respond self-protectively in the face of stressful life events-it may also have a significant biological cost. It may predispose the child's neural networks to periods of instability-presenting clinically as PNES-when the neural networks are faced with perturbations in energy flow or with additional demands.

Neurocognitive functioning in patients with conversion disorder/functional neurological disorder

Neurocognitive symptoms are common in individuals with somatic symptom and related disorders (SSRD), but little is known about the specific impairments in neurocognitive domains in patients with conversion disorder (CD)/functional neurological disorder (FND). This study examines neurocognitive functioning in patients with CD/FND compared to patients with other SSRD. The sample consisted of 318 patients. Twenty‐nine patients were diagnosed with CD/FND, mean age 42.4, standard deviation (SD) = 13.8 years, 79.3% women, and 289 patients had other SSRD (mean age 42.1, SD = 13.3, 60.2% women). Patients completed a neuropsychological test battery that addressed a broad range of neurocognitive domains, including information processing speed, attention and executive functioning. Patients with CD/FND had clinically significant neurocognitive deficits in all neurocognitive domains based on normative data comparison. Patients with CD/FND also performed significantly worse than patients with other SSRD on information processing speed (Digit Symbol Substitution Test (V = .115, p = .035), Stroop Color–Word Test (SCWT) card 1 (V = .190, p = .006), and SCWT card 2 (V = .244, p < .001). No CD/FND vs. other SSRD differences were observed in other neurocognitive domains. These findings indicate the patients with CD/FND perform worse on information processing speed tests compared to patients with other SSRD.

Heart rate variability related to season of birth: A replication study

Low heart rate variability (HRV) has strongly been associated with an increased risk for cardiovascular disease. With cardiovascular disease being the number one cause of global deaths, factors that influence its development are relevant to understand. Season of birth has been suggested as one of the factors influencing the development of HRV. The current study was set up to replicate the finding that men born in winter have higher HRV later in life compared to those born in other seasons. To this end, we studied a sample of 1,871 healthy participants from the Brain Resource International Database during rest and during task. Furthermore, sex and age differences and associations with personality traits and psychiatric symptoms were explored. We replicated the earlier finding that men born in winter have a lower ratio of low frequency (LF) power to high frequency (HF) power during rest compared to summer and fall, and, although less pronounced, higher HF compared to summer. A difference between summer and winter for LF/HF in men was internally replicated using data recorded during task. Additionally, for both sexes, LF/HF ratio increased with age, and LF and HF both decreased. In general, LF/HF was lower in women, but heart rate was higher. In men, low HRV was associated with depression and the personality trait openness. In conclusion, results from a large multicenter data set covering the entire lifespan demonstrate that HRV changes with age in both sexes and confirm that season of birth influences HRV later in life in men.

This is a replication study, showing heart rate variability (HRV) to vary with season of birth (SoB). Since both HRV and SoB have been related to cardiovascular disease, the relationship is relevant to understand. We used an almost five times larger sample than the original sample, covering wider geographic areas and the full lifespan. Additionally, age and sex differences in HRV were found. Replicating earlier findings provides solid evidence for a relationship between SoB and HRV later in life, thereby providing insights on how HRV develops and ultimately how increased risk for cardiovascular disease can be reduced.

Neuro-Cognition in Adolescents with Dissociative Disorder: A Study from a Tertiary Care Center of North India

BACKGROUND

Dissociative disorder is a common neurotic disorder. Patients with dissociative disorder experience significant psychological distress and have deficits in various domains of neurocognitive functions.

OBJECTIVE

To assess the neurocognitive functioning of adolescents diagnosed with dissociative disorder and compare it with that of healthy controls.

MATERIALS AND METHODS

This is a cross-sectional observational study conducted on adolescents diagnosed with dissociative disorder, attending child and adolescent specialty clinic of a tertiary care hospital of North India from October 2016 to February 2017. Healthy control subjects were also recruited for comparison on study variables. Malin's Intelligence Scale for Indian children and standardized neuropsychological tools were administered for the assessment of intellectual functioning and neurocognitive functioning.

RESULTS

A total of 50 participants with dissociative disorder and 50 healthy controls completed the study. Participants of both the groups had an average level of intellectual functioning. Participants with dissociative disorder showed poorer performance on tasks of attention and executive functions. After the Bonferroni correction, deficits were detected in the domains of coding (P = 0.0012), maze (P = 0.0001), and mathematics (P = 0.0016).

CONCLUSIONS

Adolescents with dissociative disorder have impaired neurocognitive functions in comparison to healthy controls.

The Price of Needing to Belong: Neurobiology of Working Through Attachment Trauma

Belonging is fundamental to health and well-being. Complex relational trauma disrupts attachments, negatively impacting developing neurobiology and has significant implications for attachment behaviors, mental health, and treatment planning. We have developed a dynamic relational (DR) model of psychotherapy that aims to restore a healthy sense of belonging, targeting levels of activation and integration of large scale neural networks in the service of increasing the emotional capacities (attunement, processing, regulation, and expression) required to work through attachment trauma and establish healthy relationships. Our DR model provides an organizing framework through which to understand both the phenomenology observed in complex trauma and the mechanisms of therapeutic change. Our approach informs the weighting and timing of interventions to actively address capacity deficits, ego-syntonic symptoms, and unconscious resistance. The implications of this model also relate to the pathogenesis of mental disorder, and suggest prevention and early intervention efforts focus on modulation of subcortical (autonomic) responses and the encouragement of balanced cortical integration to enhance cognitive flexibility/psychological resilience. Ultimately, interventions based on our systematic model may modulate the genetic diathesis and comorbidities of relational trauma and increase psychological resilience.

Processing of Emotion in Functional Neurological Disorder

Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.

When symptoms don't fit: a case series of conversion disorder in the pediatric otolaryngology practice

Background

Conversion disorder refers to functional bodily impairments that can be precipitated by high stress situations including trauma and surgery. Symptoms of conversion disorder may mimic or complicate otolaryngology diseases in the pediatric population.

Case presentation

In this report, the authors describe 3 cases of conversion disorder that presented to a pediatric otolaryngology-head and neck surgery practice. This report highlights a unique population of patients who have not previously been investigated. The clinical presentation and management of these cases are discussed in detail. Non-organic otolaryngology symptoms of conversion disorder in the pediatric population are reviewed. In addition, we discuss the challenges faced by clinicians in appropriately identifying and treating these patients and present an approach to management of their care.

Conclusion

In this report, the authors highlight the importance of considering psychogenic illnesses in patients with atypical clinical presentations of otolaryngology disorders.

"Motoring in idle": The default mode and somatomotor networks are overactive in children and adolescents with functional neurological symptoms

Objective

Children and adolescents with functional neurological symptom disorder (FND) present with diverse neurological symptoms not explained by a disease process. Functional neurological symptoms have been conceptualized as somatoform dissociation, a disruption of the brain's intrinsic organization and reversion to a more primitive level of function. We used EEG to investigate neural function and functional brain organization in children/adolescents with FND.

Method

EEG was recorded in the resting eyes-open condition in 57 patients (aged 8.5-18 years) and 57 age- and sex-matched healthy controls. Using a topographical map, EEG power data were quantified for regions of interest that define the default mode network (DMN), salience network, and somatomotor network. Source localization was examined using low-resolution brain electromagnetic tomography (LORETA). The contributions of chronic pain and arousal as moderators of differences in EEG power were also examined.

Results

Children/adolescents with FND had excessive theta and delta power in electrode clusters corresponding to the DMN-both anteriorly (dorsomedial prefrontal cortex [dmFPC]) and posteriorly (posterior cingulate cortex [PCC], precuneus, and lateral parietal cortex)-and in the premotor/supplementary motor area (SMA) region. There was a trend toward increased theta and delta power in the salience network. LORETA showed activation across all three networks in all power bands and localized neural sources to the dorsal anterior cingulate cortex/dmPFC, mid cingulate cortex, PCC/precuneus, and SMA. Pain and arousal contributed to slow wave power increases in all three networks.

Conclusions

These findings suggest that children and adolescents with FND are characterized by overactivation of intrinsic resting brain networks involved in threat detection, energy regulation, and preparation for action.

Gender differences in the prevalence and impact factors of hysterical tendencies in adolescents from three eastern Chinese provinces

BACKGROUND

Few studies have attempted to compare the differences in the prevalence and impact factors of hysterical tendencies (HTs) in adolescents. Thus, the aim of this study was to examine gender differences in the prevalence and impact factors of adolescents' HTs across three eastern Chinese provinces (Anhui, Jiangsu, and Zhejiang).

METHODS

A multicenter, school-based, cross-sectional study was conducted in three provinces (Anhui, Jiangsu, and Zhejiang) in China in 2014. The sample included 10,131 middle-school students aged 13-18 years who were randomly selected using a multiphase, stratified, cluster sampling technique. A two-stage appraisal procedure was used to determine the adolescents' HTs. We also designed a multicenter, school-based, case control (1329 cases with 2661 control individuals) study to collect data on the common factors affecting this population using a common protocol and questionnaire.

RESULTS

An overall positive rate of HTs among adolescents across the three eastern Chinese provinces studied was found at 13.1% (95% confidence interval (CI) 12.5-13.8%), at 14.5% (95% CI 13.3-15.7%) for females, and at 12.2% (95% CI 11.1-13.4%) for males. Gender-stratified, multiple conditional regression analyses revealed that superstitious beliefs pertaining to life, somatotype, teacher-student satisfaction, and family achievement orientation were significantly linked to HTs only in males, while left-behind adolescents, emotional and social adaptation, teacher-student support, family cohesion, and the Hospital Anxiety and Depression Scale - depression scores were significantly associated with female HTs only. The models indicated that of all the independent variables studied, family medical history was the strongest impact factor for both male HTs (adjusted matched odds ratio (amOR) = 2.92, 95% CI = 1.84-4.86) and female HTs (amOR = 2.74, 95% CI = 1.59-4.98).

CONCLUSIONS

HTs are prevalent among adolescents in the three eastern Chinese provinces studied. Gender differences in the prevalence and impact factors of HTs are significant in adolescents, and HTs seem to affect more females than males. Therefore, sex-specific intervention programs against HTs in adolescents should be considered to reduce HT prevalence in adolescents by modifying influential social, school, and family factors.

Grey matter abnormalities in children and adolescents with functional neurological symptom disorder

Objective

Functional neurological symptom disorder refers to the presence of neurological symptoms not explained by neurological disease. Although this disorder is presumed to reflect abnormal function of the brain, recent studies in adults show neuroanatomical abnormalities in brain structure. These structural brain abnormalities have been presumed to reflect long-term adaptations to the disorder, and it is unknown whether child and adolescent patients, with illness that is typically of shorter duration, show similar deficits or have normal brain structure.

Method

High-resolution, three-dimensional T1-weighted magnetic resonance images (MRIs) were acquired in 25 patients (aged 10–18 years) and 24 healthy controls. Structure was quantified in terms of grey matter volume using voxel-based morphometry. Post hoc, we examined whether regions of structural difference related to a measure of motor readiness to emotional signals and to clinical measures of illness duration, illness severity, and anxiety/depression.

Results

Patients showed greater volumes in the left supplementary motor area (SMA) and right superior temporal gyrus (STG) and dorsomedial prefrontal cortex (DMPFC) (corrected p < 0.05). Previous studies of adult patients have also reported alterations of the SMA. Greater SMA volumes correlated with faster reaction times in identifying emotions but not with clinical measures.

Conclusions

The SMA, STG, and DMPFC are known to be involved in the perception of emotion and the modulation of motor responses. These larger volumes may reflect the early expression of an experience-dependent plasticity process associated with increased vigilance to others' emotional states and enhanced motor readiness to organize self-protectively in the context of the long-standing relational stress that is characteristic of this disorder.

•

We used high-resolution MRI to investigate brain structure in children presenting with acute functional neurological symptom disorder (FND).

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Patients had multiple antecedent stressors, a long-standing history of relational stress and at-risk attachment strategies.

•

Patients had greater volumes in the SMA—where motor-, cognitive-, and emotion-processing signals interact to influence motor function.

•

FND may involve experience-dependent changes in brain structure alongside experience-dependent changes in brain function.

Don't forget the siblings: School-aged siblings of children presenting to mental health services show at-risk patterns of attachment

Family therapists understand that children presenting for treatment are often bearers of symptoms signalling relational problems within the family system. Rather than addressing the children's symptoms in isolation, family therapists typically take those relational problems as their starting point in therapy. This study used the School-aged Assessment of Attachment (SAA) to assess the self-protective (attachment) strategies of the siblings of children presenting for psychiatric evaluation and also of the siblings of control children drawn from the normative population. Siblings of children in the clinical group were much more likely than siblings of control children to use at-risk self-protective strategies and to have markers suggestive of unresolved loss or trauma. School-aged siblings were found to use a broad range of strategies, and the pattern of change from first born to later born involved either a reversal of strategy or a shift to a more complex strategy. The study highlights that siblings of children presenting to mental health services are significantly affected by family relational stress. A family systems approach to assessment, one that enquires about the wellbeing of all family members, will ensure that the emotional needs of siblings are also addressed during the therapy process.

The respiratory control of carbon dioxide in children and adolescents referred for treatment of psychogenic non-epileptic seizures

Psychogenic non-epileptic seizures (PNES) are a common problem in paediatric neurology and psychiatry that can best be understood as atypical responses to threat. Threats activate the body for action by mediating increases in arousal, respiration, and motor readiness. In previous studies, a range of cardiac, endocrine, brain-based, attention-bias, and behavioral measures have been used to demonstrate increases in arousal, vigilance, and motor readiness in patients with PNES. The current study uses respiratory measures to assess both the motor readiness of the respiratory system and the respiratory regulation of CO₂. Baseline respiratory rates during clinical assessment and arterial CO₂ levels during the hyperventilation component of routine video electroencephalogram were documented in 60 children and adolescents referred for treatment of PNES and in 50 controls. Patients showed elevated baseline respiratory rates [t(78) = 3.34, p = .001], with 36/52 (69%) of patients [vs. 11/28 (39%) controls] falling above the 75th percentile (χ² = 6.7343; df = 1; p = .009). Twenty-eight (47%) of patients [vs. 4/50 (8%) controls] showed a skewed hyperventilation-challenge profile—baseline PCO₂ <36 mmHg, a trough PCO₂ ≤ 20 mmHg, or a final PCO₂ <36 mmHg after 15 min of recovery—signaling difficulties with CO₂ regulation (χ² = 19.77; df = 1; p < .001). Children and adolescents with PNES present in a state of readiness-for-action characterized by high arousal coupled with activation of the respiratory motor system, increases in ventilation, and a hyperventilation-challenge profile shifted downward from homeostatic range. Breathing interventions that target arousal, decrease respiratory rate, and normalize ventilation and arterial CO₂ may help patients shift brain–body state and avert PNES episodes.

Pediatric Somatic Symptom Disorders

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

Aberrant gamma band cortical sources and functional connectivity in adolescents with psychogenic non-epileptic seizures: A preliminary report

Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures, but lack clinically evident abnormal electrical activity in the brain. We aimed to assess resting gamma spectral power, current source distribution and functional connectivity in adolescents with PNES. Interictal, 32 channels electroencephalographic recording of 15 adolescents with PNES was compared with 10 matched healthy controls. Spectral power, current source distribution and lagged linear coherence were assessed. Statistically significant gamma spectral power, cortical sources and connectivity pattern was found in some brain areas. Region specific aberrant gamma activity and its relationship to psychopathology are discussed.

Cortical arousal in children and adolescents with functional neurological symptoms during the auditory oddball task

OBJECTIVE

Stress, pain, injury, and psychological trauma all induce arousal-mediated changes in brain network organization. The associated, high level of arousal may disrupt motor-sensory processing and result in aberrant patterns of motor function, including functional neurological symptoms. We used the auditory oddball paradigm to assess cortical arousal in children and adolescents with functional neurological symptom disorder.

METHOD

Electroencephalogram (EEG) data was collected in fifty-seven children and adolescents (41 girls; 16 boys, aged 8.5-18 years) with acute functional neurological symptoms and age- sex- matched controls during a conventional auditory oddball task. The high-resolution fragmentary decomposition technique was used to analyse the amplitude of event-related potentials (ERPs) to target tones at midline sites (Fz, Cz, and Pz).

RESULTS

Compared to age- and sex-matched controls, and across all three midline sites, children and adolescents with functional neurological symptoms showed increased amplitude of all ERP components (P50, N100, P200, N200, and P300) (t-value range 2.28-8.20; p value-range 0.023 to < 0.001) to the emotionally-neutral auditory stimulus.

CONCLUSIONS

Our findings add to a growing literature indicating that a baseline state of high arousal may be a precondition for generating functional neurological symptoms, a finding that helps explain why a range of psychological and physiological stressors can trigger functional neurological symptoms in some patients. Interventions that target cortical arousal may be central to the treatment of paediatric patients with functional neurological symptom disorder.

Validation of the School-age Assessment of Attachment in a short-term longitudinal study

This study tested the validity of the School-aged Assessment of Attachment (SAA) in terms of matches from the well-validated Preschool Assessment of Attachment (PAA) to the SAA 6 months later. It also addressed validity in terms of mental health services and measures of stress, depression and anxiety.

HYPOTHESES

Children's SAA classifications were predicted to match their 6 months' previous PAA classifications and indicators of maternal, child and family stress. The study used a two-group comparative design, involving normative and clinical children and their mothers.

METHOD

The participants were 50 children between 5.5 and 5.9 years of age. Each child participated with his or her mother in a PAA, and then 6 months later each child responded to the SAA story cards as well as self-report assessments of stress, anxiety and depression.

RESULTS

Concordance of A, B, C and A/C attachment classifications was found between the PAA and SAA in 34 of 48 children. There was a strong relation between referral status (clinical or normative) and both PAA and SAA attachment classifications. In every non-matching case, a normative child had an attachment classification indicative of risk, indicating that the direction of errors was false positives as opposed to false negatives.

CONCLUSIONS

This evidence supports the validity and clinical utility of the SAA.

Reduction of autonomic regulation in children and adolescents with conversion disorders

OBJECTIVE

Conversion symptoms--functional neurological disturbances of body function--occur in association with extreme arousal, often in the context of emotional distress. The mechanisms that determine how and why such symptoms occur remain unknown. In this study, we used cardiac measures to assess arousal and cardiac autonomic regulation in children and adolescents who presented with acute conversion symptoms.

METHODS

Heart rate was recorded in 57 children and adolescents (41 girls; 8.5-18 years old) with acute conversion symptoms and 57 age- and sex-matched healthy controls, during a resting condition and then during tasks involving cognitive and emotional activation. Arousal and autonomic regulation were assessed by measures of heart rate and heart rate variability. Psychological measures included attachment and emotional distress.

RESULTS

Children and adolescents with conversion symptoms displayed higher autonomic arousal than did the controls, both at baseline and during task conditions (higher heart rate: baseline mean [standard deviation] = 82 [9.49] versus 74 [10.79] beats/min, p < .001; lower root mean squared successive differences-heart rate variability: 45.35 [27.97] versus 58.62 [25.69] ms(2), p = .012; and lower high-frequency heart rate variability: 6.50 [1.19] versus 7.01 [0.95] ln[ms(2)] p = .017), and decreased autonomic regulation (attenuation of heart rate increases across tasks). The baseline pattern of increased autonomic arousal was especially pronounced in children with coercive-preoccupied patterns of attachment. Autonomic measures were not correlated with measures of emotional distress.

CONCLUSIONS

High autonomic arousal may be a precondition for generating conversion symptoms. Functional dysregulations of the cardiac, respiratory, and circulatory systems may mediate fainting episodes and nonepileptic seizures, and aberrant patterns of functional connectivity between motor areas and central arousal systems may be responsible for generating motor conversion symptoms.

Conversive disorders among children and adolescents: towards new "complementarist" paradigms?

This paper aims to describe current questions concerning conversive disorders among children and adolescents. We first describe prevalence and clinical characteristics of these. Many unresolved questions remain. Why do patients show excess, or loss of function? Attachment theory offers a relevant framework to answer this question. Does neurobiology of conversion disorders shed light on conversive processes? Current neurobiological research paradigms focus on the symptom, trying to infer processes, instead of proposing paradigms that test theoretical hypotheses. The most convincing theoretical framework that has already proposed a coherent theory of conversion is a psychodynamic one, which has not yet been tested with neurobiological paradigms. The interest of studying child and adolescent conversive disorders is to provide a means to more deeply investigate the two challenges we face: theoretical, and clinical ones. It provides the opportunity to access a pathopsychological process at its roots, not yet hidden by many defensive, rationalizing attitudes, and to better explore environmental features. We propose a "complementarist" model, which allows the combination of different approaches (neural, cognitive, environmental, attachment, intra-psychic) and permits proposal of different levels of therapeutic targets and means.