Somatization and conversion disorder

Hypnotherapy and IBS: Implicit, long-term stress memory in the ENS?

The association between irritable bowel syndrome (IBS) and psychiatric and mood disorders may be more fundamental than was previously believed. Prenatal, perinatal, postnatal, and early-age conditions can have a key role in the development of IBS. Subthreshold mental disorders (SMDs) could also be a significant source of countless diverse diseases and may be a cause of IBS development. We hypothesize that stress-induced implicit memories may persist throughout life by epigenetic processes in the enteric nervous system (ENS). These stress-induced implicit memories may play an essential role in the emergence and maintenance of IBS. In recent decades, numerous studies have proven that hypnosis can improve the primary symptoms of IBS and also reduce noncolonic symptoms such as anxiety and depression and improve quality of life and cognitive function. These significant beneficial effects of hypnosis on IBS may be because hypnosis allows access to unconscious brain processes.

Neuromodulation for the treatment of functional neurological disorder and somatic symptom disorder: a systematic review

Functional neurological disorder and somatic symptom disorder are complex neuropsychiatric conditions that have been linked to circuit-based dysfunction of brain networks. Neuromodulation is a novel therapeutic strategy capable of modulating relevant brain networks, making it a promising potential candidate for the treatment of these patient populations. We conducted a systematic review of Medline, Embase and PsycINFO up to 4 March 2021. Trials investigating neuromodulation devices for the treatment of functional neurological disorder or somatic symptom disorder were selected. Extracted variables included study design, demographic and clinical characteristics, psychiatric comorbidity, neurostimulation protocols, clinical outcome measures and results. 404 studies were identified with 12 meeting inclusion criteria. 221 patients were treated in the included studies with mean study sample size of 18 (4-70). Five studies were randomised clinical trials. Functional motor symptoms (six weakness, four movement disorders) were the most studied subpopulations. Transcranial magnetic stimulation (TMS) was the most frequently used device (10 studies), followed by electroconvulsive therapy (one study) and direct-current stimulation (one study). Treatment protocols varied in intended therapeutic mechanism(s): eight studies aimed to modulate underlying network dysfunction, five aimed to demonstrate movement (one also leveraged the former) and three boosted their primary mechanism with enhanced suggestion/expectation. All but one study reported positive results; however, methodological/outcome heterogeneity, mixed study quality and small sample sizes precluded quantitative meta-analysis. Neuromodulation, particularly TMS for the treatment of functional motor symptoms, shows preliminary promise in a growing line of research. Larger, sham-controlled studies are needed to further establish efficacy and better understand therapeutic mechanisms.

Prognosis in functional and recognised pathophysiological neurological disorders - a shared basis

OBJECTIVE

To compare self-reported outcomes, clinical trajectory and utility of baseline questionnaire responses in predicting prognosis in functional and recognised pathophysiological neurological disorders.

METHODS

Baseline data on 2581 patients included health-related quality of life, psychological and physical symptoms, illness perceptions, consultation satisfaction and demographics. The prospective cohort included neurology outpatients classified with a functional (reporting symptoms 'not at all' or 'somewhat explained' by 'organic disease'; n = 716) or recognised pathophysiological disorder ('largely' or 'completely explained'; n = 1865). Logistic regression and deep neural network models were used to predict self-reported global clinical improvement (CGI) at 12-months.

RESULTS

Patients with functional and recognised pathophysiological disorders reported near identical outcomes at 12-months with 67% and 66% respectively reporting unchanged or worse CGI. In multivariable modelling 'negative expectation of recovery' and 'disagreement with psychological attribution' predicted same or worse outcome in both groups. Receipt of disability-related state benefit predicted same or worse CGI outcome in the functional disorder group only (OR = 2.28 (95%-CI: 1.36-3.84) in a group-stratified model) and was not related to a measure of economic deprivation. Deep neural network models trained on all 92 baseline features predicted poor outcome with area under the receiver-operator curve of 0.67 in both groups.

CONCLUSIONS

Those with functional and recognised pathophysiological neurological disorder share similar outcomes, clinical trajectories, and poor prognostic markers in multivariable models. Prediction of outcome at a patient level was not possible using the baseline data in this study.

A systematic review of personality temperament models related to somatoform disorder with main focus on meta-analysis of Cloninger's theory components

The systematic review aims to identify four personality temperament models related to somatoform disorder with the main focus on the meta-analysis of temperaments and characters in Cloninger's theory. The literature search was performed on PubMed (Medline), Scopus, Web of Science, Cochrane, and ProQuest for all articles published in English from January 1990 to April 2019. Due to heterogeneity, pooled estimates of the standard mean difference between cases and controls were calculated using the random-effects model. Based on our inclusion criteria, 14 studies were identified, 7 of which were included in the meta-analysis. The results show that there is a significant difference between cases and controls with regard to harm avoidance (HA) (z = 5.322, P < 0.001), self-directedness (z = -4.719, P < 0.001), and self-transcendence (z = 2.848, P = 0.004). Compared to controls, HA and self-transcendence were higher and self-directedness was lower in cases. With regard to other subscales, there was no difference between the two groups (P > 0.05). The publication bias was not seen (P > 0.05 for Egger statistics). Up to now, very few studies have been focused on the relationship between personality temperament models and somatoform disorder. Among the components of the Cloninger's model, the poor self-directedness along with the abnormally high self-transcendence and HA is the personality component related to the somatoform disorder. Thus, Cloninger's model may potentially draw a personality profile for vulnerability to somatoform disorder. Given the limited number of studies available, future studies may challenge the results of the present study.

Changes in psychosocial well-being after mindfulness-based stress reduction: a prospective cohort study

Objectives: The primary purpose of the current study was to assess the effects of a mindfulness-based stress reduction (MBSR) program, facilitated by non-psychologist clinicians, for improving psychosocial well-being. A secondary purpose of the current study was to explore the role of self-compassion as a potential underlying factor for improvements in emotional distress. Application of these findings to a physical therapy setting is provided. Methods: One hundred and thirty participants with a variety of medical complaints completed an eight-week MBSR program at Vanderbilt University's Osher Center for Integrative Medicine. Prior to the intervention and at the eight-week time point, participants completed measures for emotional distress (Brief Symptom Inventory), stress (Perceived Stress Scale-10), mindfulness (Mindfulness Attention and Awareness Scale), and self-compassion (Self-Compassion Scale). Wilcoxon signed-rank test was used to evaluate changes in outcomes after MBSR. Linear model estimation using ordinary least squares was used to evaluate the association between changes in self-compassion with changes in emotional distress. Results: Following MBSR, participants reported significant reductions in emotional distress (p < 0.001). Additionally, participants reported improvements in mindfulness and self-compassion (p < 0.001). Linear regression model revealed that changes in self-compassion were significantly associated with changes in emotional distress (p < 0.001). Discussion: An MBSR program conducted by non-psychologist clinicians was associated with improvements in emotional distress, stress, and self-compassion. MBSR is a promising adjunct intervention in which principles can be integrated within a physical therapy approach for chronic conditions. Level of Evidence: 3B.

Assessing older adults in civil litigation cases

With the population aging, the legal and mental health systems need to be prepared for cases that involve older adults beyond the customary matters of guardianship and competency. Assessing older adults with the current tests raises concerns because these measures may not be adequately normed for this age group. Malingering, factitious disorders, and somatoform disorders are discussed due to health-related issues of normal aging. These topics complicate the assessment procedure and need consideration because they may affect the claimant's performance or symptom presentation. Although claims of posttraumatic stress disorder (PTSD) are common in civil litigation cases, it can be additionally complex in older adults. The evaluator needs to weigh not only factors related to the normal biological process of aging but also those that are attendant with the litigation.

Outlining the psychopathology behind a case of conversion syndrome: Is a holistic approach beneficial?

Conversion disorder refers to a set of symptoms where no relevant organic cause is found. These include sensory/motor disturbances, and other neurological symptoms, such as pseudoseizures. Patients with this condition may, by having it, achieve a primary or secondary gain. The condition should be diagnosed when all the relevant investigations are inconclusive. In this case, we use the bio-psycho-social model for the interpretation and guidance of treatment. We also demonstrate how a holistic approach is beneficial when it comes to a multi-dimensional interpretation of such a case. This review outlines a case of a patient with several neurological and orthopedic problems who failed to improve with several treatment plans and surgical interventions. After several years of medical and surgical consultations, a thorough analysis by psychiatrists was made, resulting in a diagnosis of conversion syndrome. The patient gradually improved on psychiatric treatment, including psychotherapy, and with the necessary psychiatric follow-ups.

Conversion paralysis after cervical spine arthroplasty: a case report and literature review

We report a case of conversion paralysis after cervical spine arthroplasty performed in a 45-year-old woman to treat cervico-brachial neuralgia due to a left-sided C6-C7 disc herniation. Upon awakening from the anaesthesia, she had left hemiplegia sparing the face, with normal sensory function. Magnetic resonance imaging (MRI) of the brain ruled out a stroke. MRI of the spinal cord showed artefacts from the cobalt-chrome prosthesis that precluded confident elimination of mechanical spinal cord compression. Surgery performed on the same day to substitute a cage for the prosthesis ruled out spinal cord compression, while eliminating the source of MRI artefacts. Findings were normal from follow-up MRI scans 1 and 15days later, as well as from neurophysiological testing (electromyogram and motor evoked potentials). The deficit resolved fully within the next 4days. A psychological assessment revealed emotional distress related to an ongoing divorce. The most likely diagnosis was conversion paralysis. Surgeons should be aware that conversion disorder might develop after a procedure on the spine, although the risk of litigation requires re-operation. Familiarity with specific MRI sequences that minimise artefacts can be valuable. A preoperative psychological assessment might improve the detection of patients at high risk for conversion disorder.

Familial and socio-economic correlates of somatisation disorder

Background

Somatisation disorder can result from an interplay between suboptimal family environment and socio-economic deprivation, which enhances the underlying cognitive tendency for this disorder. There are pertinent familial and socio-economic factors associated with this disorder, but research addressing this is sparse.

Aim and setting

The study aims to evaluate family and socio-economic factors that are associated with somatisation disorder amongst patients presenting to the Family Medicine clinic, University College Hospital, Ibadan, Nigeria.

Methods

This is an observational case-control study of 120 participants who presented to the clinic between May and August 2009. Data collection was by interviewer-administered structured questionnaire using the World Health Organization Screener for Somatoform Disorder and Somatoform Disorder Schedule to ascertain somatisation in 60 patients who were then matched with 60 controls. The respondents’ demographic and family data were also collected and their interpersonal relationships were assessed with the Family Relationship Index.

Results

The somatising patients were mostly females (70%), with a female to male ratio of 2.3:1 and mean age of 43.65 ± 13.04years.Living in a polygamous family (as any member of the family) was significantly related to somatisation (p = 0.04). Somatisation was also more common in people who were separated, divorced or widowed (p = 0.039). Somatisers from a lower social class or those earning below a dollar a day experienced poorer cohesion (p = 0.042) and more conflicts (p = 0.019) in their interpersonal relationship.

Conclusion

This study was able to demonstrate that a polygamous family setting, disrupted marriage, low social status and financial constraints are correlates of somatisation. It is of essence to identify these factors in holistic management of somatising patients.

Electroconvulsive therapy treatment in patients with somatic symptom and related disorders

OBJECTIVE

Medically unexplained somatic complaints are highly prevalent, and lead to significant impairment and disability. The number of effective treatment modalities for somatic symptom and related disorders (SSDs) or somatoform disorders (SDs) remains limited. To date, there is no formal indication for electroconvulsive therapy (ECT) in SSD or SD. We report on the largest case series to date regarding the effectiveness of ECT in patients with SSD and SD.

METHODS

A retrospective chart review of all patients treated with an index course of ECT at the Neuropsychiatric Program at the University of British Columbia Hospital from 2000 to 2010 was conducted. The primary outcomes consisted of changes in pseudoneurologic symptoms, pain symptoms, cardiopulmonary symptoms, and gastrointestinal symptoms. Complaints were examined pre- and post-ECT.

RESULTS

Twenty-eight participants were included in this study. Twenty-one participants received right unilateral ECT. Six received bifrontal ECT. One received bitemporal ECT. Eighteen of 21 participants reported improvement in pseudoneurologic symptoms; eleven of 14 participants reported improvement in pain symptoms; one participant reported improvement in cardiopulmonary symptoms; and one of two participants reported improvement in gastrointestinal symptoms. This paper discusses the putative mechanism of action of ECT in the treatment of SD/SSD.

CONCLUSION

This retrospective study suggests that ECT could be included as part of the existing treatment for refractory SSD and SD, particularly in refractory cases with comorbid mood disorders.

The use of effective treatments: the case of an adolescent girl with anorexia nervosa in the context of a conversion disorder

The use of empirically supported treatment (EST) has been shown to enhance treatment outcome. The purpose of this case study was to suggest that ESTs further encourage effective reconceptualisation and the ongoing delivery of effective treatment, especially in the case of complex or atypical presentations or response to treatment. This report describes the case of an adolescent girl who underwent Maudsley family-based treatment for anorexia nervosa (AN) for a period of 12 months. Atypical response lead to an understanding of her presentation as representing a primary conversion disorder, within which AN symptoms were conceptualised as another somatic conversion of emotional distress. The report details her clinical presentation and management over the course of her illness. The case offers an important opportunity to explore the central role of the use of ESTs in guiding effective treatment delivery.

Multimodal psychodynamic psychotherapy induces normalization of reward related activity in somatoform disorder

OBJECTIVES

Somatoform disorder patients demonstrate a disturbance in the balance between internal and external information processing, with a decreased focus on external stimulus processing. We investigated brain activity of somatoform disorder patients, during the processing of rewarding external events, paying particular attention to the effects of inpatient multimodal psychodynamic psychotherapy.

METHODS

Using fMRI, we applied a reward task that required fast reactions to a target stimulus in order to obtain monetary rewards; a control condition contained responses without the opportunity to gain rewards. Twenty acute somatoform disorder patients were compared with twenty age-matched healthy controls. In addition, 15 patients underwent a second scanning session after participation in multimodal psychodynamic psychotherapy.

RESULTS

Acute patients showed diminished hemodynamic differentiation between rewarding and non rewarding events in four regions, including the left postcentral gyrus and the right ventroposterior thalamus. After multimodal psychodynamic psychotherapy, both regions showed a significant normalization of neuronal differentiation.

CONCLUSION

Our results suggest that diminished responsiveness of brain regions involved in the processing of external stimuli underlies the disturbed balance of internal and external processing of somatoform disorder patients. By providing new approaches to cope with distressing events, multimodal psychodynamic psychotherapy led to decreased symptoms and normalization of neuronal activity.

Clinical profile of somatoform disorders in children

OBJECTIVE

To study the clinical profile, socio-demographic features, psychosocial stressors and outcome of somatoform disorders in children

METHODS

Children up to the age of 18 year presenting with unexplained physical symptoms over a period of 6 months were evaluated. A detailed history and physical examination was carried out. Appropriate investigations were undertaken to exclude organic causes. Diagnosis was made according to DSM-IV-TR criteria.

RESULTS

Forty-five children were diagnosed with somatoform disorders during the study period. The prevalence was 0.5% and 0.9% among outdoor and indoor patients, respectively. Conversion disorder (48.9%) was the commonest followed by other somatoform disorders (26.7%). Pseudoseizures and fainting attacks in conversion disorder and pain abdomen and general body pain in somatoform disorder were the commonest symptoms. Male to female ratio was 2.2:1. Urban children (25) were represented more than rural children (20). Stress factors were identified in 71.1% patients, which included fear of school or examinations. Thirty-three patients (73.3%) remained asymptomatic after counseling whereas, 8 patients (17.6%) had relapse requiring further counseling. Four patients (8.8%) showed no improvement and needed psychiatric evaluation.

CONCLUSIONS

Early referral to mental health professional is required to avoid unnecessary investigations and delay in diagnosis of somatoform disorders in children.

Psychodynamics in medically ill patients

This article explores the role of psychodynamics as it applies to the understanding and treatment of medically ill patients in the consultation-liaison psychiatry setting. It provides historical background that spans the eras from Antiquity (Hippocrates and Galen) to nineteenth-century studies of hysteria (Charcot, Janet, and Freud) and into the twentieth century (Flanders Dunbar, Alexander, Engle, and the DSM). The article then discusses the effects of personality on medical illness, treatment, and patients' ability to cope by reviewing the works of Bibring, Kahana, and others. The important contribution of attachment theory is reviewed as it pertains the patient-physician relationship and the health behavior of physically ill patients. A discussion of conversion disorder is offered as an example of psychodynamics in action. This article highlights the important impact of countertransference, especially in terms of how it relates to patients who are extremely difficult and "hateful," and explores the dynamics surrounding the topic of physician-assisted suicide, as it pertains to the understanding of a patient's request to die. Some attention is also given to the challenges surrounding the unique experience of residents learning how to treat medically ill patients on the consultation-liaison service. Ultimately, this article concludes that the use and understanding of psychodynamics and psychodynamic theory allows consultation-liaison psychiatrists the opportunity to interpret the life narratives of medically ill patients in a meaningful way that contributes importantly to treatment.

The hypnotic diagnostic interview for hysterical disorders, pediatric form

This article reports on the use of hypnosis to facilitate the diagnostic process in two cases of pediatric hysterical reactions. The Hypnotic Diagnostic Interview for Hysterical Disorders (HDIHD), an interview tool, specifically designed for these cases, is reported. The first case was an adolescent male with motor Conversion Disorder manifested as paralysis of his lower limbs. The second was a preadolescent girl with sensory Conversion Disorder manifested as reduction of visual field in her right eye. Freudian conceptualization of hysterical reactions was employed as the conceptual basis in the formulation of these cases. This orientation posits hysterical phenomena a psychological defense employed by individuals exposed to traumatic experiences in order to effectuate a defense from intolerable affective material. The emotionally overwhelming material converts into physical reactivity free of the traumatic consequences by keeping the intolerable images and emotions deeply repressed within the subconscious. As the focus on these cases was diagnostic, treatment efforts were avoided. As it turned out, environmental interventions, based on the obtained information from the hypnotic interviews, extinguished the symptoms. The children were symptom free at follow-up.

[Vague and diffuse symptoms in biomedicine: a review of the literature]

The purpose of this study is to chart academic output on vague and diffuse symptoms in biomedicine. As methodological tool, we conducted a bibliographic study through the Internet ranging from 1990 to 2005. Forty papers were selected and five major theme areas were established for the survey: the nomenclatures assigned to vague and diffuse symptoms; their definitions; the relevance of the theme being addressed; the criteria used to diagnose vague and diffuse symptoms; and the therapeutic actions adopted. The discussion of the findings identifies many biomedical difficulties in dealing with sufferers from undefined complaints, including: diversity and lack of conceptual precision in the use of the nomenclature; physicians who are poorly prepared to deal with these patients; demand considered as a psychic disorder; difficulties in establishing diagnostic criteria and poor use of treatment resources. This leads to the conclusion that the biomedical model behind these difficulties has few tools for dealing with the singularities of human suffering and its experiential phenomenological dimension.

Toward a general theory of unconscious processes in psychoanalysis and anesthesiology

Psychoanalysis and anesthesiology appear radically different in their clinical practice, yet they share a focus of inquiry: unconscious processes. Despite this common domain, there has been no exploration of the relationship between "the unconscious" as conceived by psychoanalysts and "surgical unconsciousness" as conceived by anesthesiologists. This is likely due to the fact that general anesthesia has been assumed to be a state in which the brain is simply "turned off." More recent neuroscientific data invalidate this assumption by demonstrating that the anesthetized brain is both cognitively dynamic and capable of implicit learning. Current perspectives on anesthetic mechanisms suggest that general anesthesia is characterized not simply by the absence of cognitive activity, but by the disintegration of cognitive activity. The cognitive unbinding paradigm of general anesthesia is discussed and its application to Wilfred Bion's theory of thinking, as well as his concept of attacks on linking, is elucidated. Based on the common structure and function of unconscious processes in psychoanalysis and anesthesiology, the foundation of a general theory is established.

Factitious Disorders: Reformulating the DSM–IV Criteria

The author criticizes and reformulates the DSM-IV criteria in a clinically and nosologically sensitive way. Criterion A, the intentional production of physical or psychological signs or symptoms, emphasizes symptoms and cannot accommodate pseudologia fantastica, voluntary false confessions, and impersonations. Criterion B, the motivation is to assume the "sick role," has no empirical content and fulfills no diagnostic function. The two criteria need reformulating in terms of lies and self-harm, respectively. Criterion C causes misdiagnosis by pushing factitious disorders into the somatoform and malingering categories and should be abandoned. The author discusses the implications for the etiology of conversion disorders and the classification of factitious disorders.

Mother-Infant Interactions in Rats Lacking CCKA Receptors

Mediation of mother-infant interactions by the brain-gut peptide cholecystokinin (CCK) was examined by observing behavior of Otsuka Long-Evans Tokushima Fatty (OLETF) rats, which lack functional CCKA receptors because of a genetic abnormality. OLETF (n = 10) and control (Long-Evans Tokushima Otsuka [LETO] n = 10) dams interacted with 1 pup of each line on Postpartum Days 6-9. OLETF pups received more body and anogenital licking and emitted substantially more ultrasonic vocalizations than LETO pups. OLETF dams carried pups less frequently and showed a nursing position more frequently than LETO dams. No significant Pup X Dam Line interactions or line differences in dams' activity were detected. The results provide convergent validity to previous pharmacological studies implicating CCK mediation of both infant and maternal behavior.