The Prevalence of Conversion Symptoms in Women From a General Turkish Population

Theory of mind and its relationship with alexithymia and quality of life in patients with psychogenic nonepileptic seizures: Comparisons with generalised epilepsy and healthy controls

OBJECTIVE

Psychogenic nonepileptic seizures (PNES) are associated with high alexithymia, social cognition problems and low quality of life (QoL). Theory of Mind (ToM) has been studied in several conditions as a significant predictor of QoL. We aimed to assess the relationship between ToM abilities, alexithymia and subjective QoL in PNES patients and compare with generalised epilepsy (ES) patients and healthy controls.

METHOD

Patients with PNES (n = 28), ES (n = 28) and healthy volunteers (n = 28) were evaluated for alexithymia and quality of life (QoL) with Toronto Alexithymia Scale-20 (TAS-20) and Short Form-36 (SF-36). Reading the Mind in the Eyes test was used for assessment of affective ToM and Hinting Task and Strange Stories tests for cognitive ToM abilities.

RESULTS

Analyses revealed lower SF-36 scores and poorer ToM performance in the PNES group compared to healthy group and poorer cognitive ToM performance than ES group. Cognitive ToM performance was inversely correlated with TAS-20 "difficulty identifying feelings" subscale and "physical functioning" subscale of SF-36 in the PNES group.

CONCLUSION

These results are consistent with previous research on PNES and other somatoform disorders and suggest that PNES is associated with impaired ToM task performance. ToM task performance might be related to specific aspects of alexithymia and QoL.

Assessing Post-Traumatic Tonic Immobility Responses: The Scale for Tonic Immobility Occurring Post-Trauma

BACKGROUND

Peri-traumatic tonic immobility has been associated with the development and course of post-traumatic stress disorder. Despite serving as an adaptive late-stage defense response, tonic immobility that continues in response to post-traumatic reminders may lead to reduced functioning and a diminished sense of well-being. At present, no validated self-report measures assess post-traumatic tonic immobility responses specifically.

METHODS

The primary objective of the present study was to evaluate the Scale for Tonic immobility Occurring Post-trauma (STOP), the first self-report measure developed to assess for the presence and severity of tonic immobility responses that persist following trauma exposure as part of post-traumatic symptomatology. Trauma-exposed clinical and non-clinical participants (N = 462) with a history of tonic immobility completed a demographic questionnaire, the STOP, and measures of post-traumatic symptoms, dissociation, anxiety, and depression.

RESULTS

STOP assessed four latent constructs, which were interpreted following the human defense cascade model. Together, these factors capture the sensorimotor and perceptual alterations, and dissociative experiences, associated with post-traumatic tonic immobility as a trauma-related altered state. Residual symptoms and the experience of negative affect following this response (including guilt and shame) are also represented. STOP scores demonstrated excellent reliability, as well as good construct and convergent validity, with other measures of dissociation and post-traumatic stress disorder. Results from the present study suggest tonic immobility is most consistent with other dissociative post-traumatic symptomatology.

CONCLUSIONS

STOP demonstrates excellent preliminary psychometric properties and may be useful for researchers and clinicians wishing to assess chronic forms of tonic immobility across trauma-exposed, clinical and community samples.

Parallel-Distinct Structures of Internal World and External Reality: Disavowing and Re-Claiming the Self-Identity in the Aftermath of Trauma-Generated Dissociation

The nature of consciousness and the autonomy of the individual's mind have been a focus of interest throughout the past century and inspired many theories and models. Revival of studies on psychological trauma and dissociation, which remained outside mainstream psychiatry, psychology, and psychoanalysis for the most part of the past century, has provided a new opportunity to revisit this intellectual and scientific endeavor. This paper attempts to integrate a series of empirical and theoretical studies on psychological consequences of developmental traumatization, which may yield further insight into factors which threaten the integrity of human consciousness. The paper proposes that an individual's experience of distorted reality and betrayal precipitates a cyclical dynamic between the individual and the external world by disrupting the developmental function of mutuality which is essential for maintenance of the integrity of the internal world while this inner world is in turn regulated vis-à-vis external reality. Dissociation -the common factor in all types of post-traumatic syndromes- is facilitated by violation of boundaries by relational omission and intrusion as represented by distinct effects and consequences of childhood neglect and abuse. Recent research conducted on clinical and non-clinical populations shows both bimodal (undermodulation and overmodulation) and bipolar (intrusion and avoidance) neurobiological and phenomenological characteristics of post-traumatic response. These seem to reflect "parallel-distinct structures" that control separate networks covering sensori-motor and cognitive-emotional systems. This understanding provides a conceptual framework to assist explanation of diverse post-traumatic mental trajectories which culminate in a common final pathway comprised of partly overlapping clinical syndromes such as complex PTSD, dissociative depression, dissociative identity disorder (DID), or "borderline" phenomena. Of crucial theoretical and clinical importance is that these maladaptive post-traumatic psychological formations are regarded as processes in their own right rather than as a personality disorder innate to the individual. Such mental division may perform in that internal detachment can serve to preserve the genuine aspects of the subject until such time as they can be reclaimed via psychotherapy. The paper attempts to integrate these ideas with reference to the previously proposed theory of the "Functional Dissociation of Self" (Şar and Öztürk, 2007).

Evaluation of oxidant, antioxidant, and S100B levels in patients with conversion disorder

INTRODUCTION

Various psychodynamic, neurobiological, genetic, and sociocultural factors are believed to be involved in the etiology of conversion disorder (CD). Oxidative metabolism has been shown to deteriorate in association with many health problems and psychiatric disorders. We evaluated oxidative metabolism and S100B levels in the context of this multifactorial disease.

METHODS

Thirty-seven patients with CD (25 females and 12 males) and 42 healthy volunteers (21 females and 21 males), all matched for age and sex, were included in this study. The total oxidant status, total antioxidant status, oxidative stress index, and S100B levels were compared between the two groups.

RESULTS

The total oxidant status, oxidative stress index, and S100B levels were significantly higher in patients with CD than in the control group, whereas the total antioxidant status was significantly lower.

CONCLUSION

CD is associated with deterioration of oxidative metabolism and increased neuronal damage.

The many faces of dissociation: opportunities for innovative research in psychiatry

It has been claimed that the progress of psychiatry has lagged behind that of other medical disciplines over the last few decades. This may suggest the need for innovative thinking and research in psychiatry, which should consider neglected areas as topics of interest in light of the potential progress which might be made in this regard. This review is concerned with one such field of psychiatry: dissociation and dissociative disorders. Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. While dissociative identity disorder (DID) is the most pervasive condition of all dissociative disorders, partial representations of this spectrum may be diagnosed as dissociative amnesia (with or without fugue), depersonalization disorder, and other specified dissociative disorders such as subthreshold DID, dissociative trance disorder, acute dissociative disorders, and identity disturbances due to exposure to oppression. In addition to constituting disorders in their own right, dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry, including neurobiological and psycho-pharmacological research. While an anti- dissociative drug does not yet exist, appropriate psychotherapy leads to considerable improvement for many patients with dissociative disorders.

A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders

Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

Trauma-related psychiatric comorbidity of somatization disorder among women in eastern Turkey

OBJECTIVE

This study sought to determine the trauma-related psychiatric comorbidity of somatization disorder among women who applied to an outpatient psychiatric unit of a general hospital in eastern Turkey.

METHODS

Forty women with somatization disorder and 40 non-clinical controls recruited from the same geographic region participated in the study. Somatization disorder and posttraumatic stress disorder (PTSD) sections of the Structured Clinical Interview for DSM-IV (including its criterion A traumatic events checklist), Dissociative Disorders Interview Schedule, Dissociative Experiences Scale (Taxon), Hamilton Depression Rating Scale, and Childhood Abuse and Neglect Questionnaire were administered to all participants.

RESULTS

A significant proportion of the women with somatization disorder had the concurrent diagnoses of major depression, PTSD, dissociative disorder, and borderline personality disorder. Women with somatization disorder reported traumatic experiences of childhood and/or adulthood more frequently than the comparison group. A significant proportion of these patients reported possession and/or paranormal experiences. Binary logistic regression analysis demonstrated that current major depression, being married, total number of traumatic events in adulthood, and reports of possession and/or paranormal experiences were independent risk factors for somatization disorder diagnosis.

CONCLUSIONS

Among women with endemically high exposition to traumatic stress, multiple somatic complaints were in a significant relationship with major depressive disorder and lifelong cumulative traumatization. While accompanying experiences of possession and paranormal phenomena may lead to seeking help by paramedical healers, the challenge of differential diagnosis may also limit effective service to this group of somatizing women with traumatic antecedents and related psychiatric comorbidities.

Predictors of suicide in patients with conversion disorder

OBJECTIVE

Previous studies have shown that the ratio of suicide attempts is between 19.6 and 34.2% in patients with conversion disorder (CD), yet few studies have addressed this issue. The present study compared demographic and clinical variables and predictors of suicide attempts in patients with CD.

METHODS

A total of 100 consecutive patients were recruited and divided into groups according to their history of suicide attempts. Socio-demographic variables such as economic status, age, gender, educational level, marital status, clinical variables such as the presence of psychiatric disorder in family, substance abuse, risky alcohol use, age of onset, subtype of CD, number of hospitalization were recorded. Participants also completed the Childhood Trauma Questionnaire (CTQ-28), Temperament and Character Inventory (TCI), Toronto Alexithymia Scale (TAS-20), Dissociative Experiences Scale (DES), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI).

RESULTS

Suicide attempters had a higher rate of risky alcohol use, more hospitalizations, and higher mean scores on the BAI, BDI, DES/DES-taxon, TAS-total and CTQ-total than did non-suicide attempters or healthy control (NHC). Patients with CD had a higher harm-avoidance and a lower self-directedness rather than NHC. Risky alcohol use, number of hospitalizations, and mean DES-taxon and emotional abuse scores were independent predictors of suicide attempts.

CONCLUSION

Our findings indicate that clinicians should be aware of the prediction of suicide in patients with CD who show dissociation and risky alcohol use. Moreover, a history of childhood emotional abuse should be considered in the management of CD. The fact that clinical variables distinguished between suicide attempters and non-attempters suggests that a history of suicide attempts may be used to clarify the heterogeneous nature of CD.

Treatment with group psychotherapy for chronic psychogenic nonepileptic seizures

Although there have been a number of psychotherapy trials for chronic psychogenic nonepileptic seizures, evidence-based treatment options are limited. We developed an eclectic group psychotherapy which combines psychoeducation and behavioral and psychoanalytic techniques. Nine patients completed 12 weeks of psychotherapy. Patients were interviewed with SCID-I. They also filled in the following measures at the beginning and end of the therapy: Beck Depression Inventory, Dissociative Experiences Scale, Spielberger State-Trait Anxiety Scale, SF-36 Life Quality Scale, and Toronto Alexithymia Scale. Seizure frequency was assessed before and after the therapy and on follow-up visits at the fourth, sixth, ninth, and twelfth months. After one year of follow-up, the decrease in seizure frequency was highly significant (p<0.001). In addition, we observed significant improvements in the mental health subscale of the SF-36 (p=0.03) and the state (p=0.006) and trait (p=0.02) subscales of the Spielberger State-Trait Anxiety Scale at the end of the therapy. These results suggest that group psychotherapy might be a treatment option for chronic psychogenic nonepileptic seizures.

A review of published research on adult dissociative identity disorder: 2000-2010

The purpose of this study was to assess the scientific and etiological status of dissociative identity disorder (DID) by examining cases published from 2000 to 2010. In terms of scientific status, DID is a small but ongoing field of study. The review yielded 21 case studies and 80 empirical studies, presenting data on 1171 new cases of DID. A mean of 9 articles, each containing a mean of 17 new cases of DID, emerged each year. In terms of etiological status, many of the central criticisms of the disorder's validity remain unaddressed. Most cases of DID emerged from a small number of countries and clinicians. In addition, documented cases occurring outside treatment were almost nonexistent. Finally, people simulating DID in the laboratory were mostly indistinguishable from individuals with DID. Overall, DID is still a topic of study, but the research lacks the productivity and focus needed to resolve ongoing controversies surrounding the disorder.

Epidemiology of Dissociative Disorders: An Overview

General psychiatric assessment instruments do not cover DSM-IV dissociative disorders. Many large-scale epidemiological studies led to biased results due to this deficit in their methodology. Nevertheless, screening studies using diagnostic tools designed to assess dissociative disorders yielded lifetime prevalence rates around 10% in clinical populations and in the community. Special populations such as psychiatric emergency ward applicants, drug addicts, and women in prostitution demonstrated the highest rates. Data derived from epidemiological studies also support clinical findings about the relationship between childhood adverse experiences and dissociative disorders. Thus, dissociative disorders constitute a hidden and neglected public health problem. Better and early recognition of dissociative disorders would increase awareness about childhood traumata in the community and support prevention of them alongside their clinical consequences.

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

BACKGROUND

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Childhood emotional abuse and dissociation in patients with conversion symptoms

AIM

The aim of the present study was to evaluate the relationship between reported childhood trauma and dissociation in patients who have a conversion symptom.

METHOD

Thirty-two outpatients with a conversion symptom were evaluated using Dissociative Experiences Scale, Somatoform Dissociation Questionnaire, Childhood Trauma Questionnaire, Spielberger Trait Anxiety Inventory, Clinician-Administered Dissociative State Scale, and Dissociative Disorders Interview Schedule.

RESULTS

A DSM-IV dissociative disorder was diagnosed in 46.9% of the patients. Conversion patients with a dissociative disorder had borderline personality disorder more frequently than those without a dissociative disorder. Among childhood trauma types, emotional abuse was the only significant predictor of dissociation in regression analysis. None of the childhood trauma types predicted borderline personality disorder criteria.

CONCLUSIONS

Borderline personality disorder, dissociation and reports of childhood emotional abuse refer to a subgroup among patients with conversion symptom. Dissociation seems to be a mediator between childhood trauma and borderline phenomena among these patients.